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LOCAL   ANESTHESIA 


LOCAL  ANESTHESIA 


DR.  ARTHUR  SCHLESINGER 

(BERLIN) 


TRANSLATED  BY 

F.  S.  ARNOLD,  B.A.,  M.B.,  B.Ch.  (Oxon.) 


ILLUSTRATED 


m 


NEW  YORK 

REBMAN     COMPANY 

Herald  Square  Building 
141-145  West  36TH  Street 


Printed  in  England 


PEEFACE 

The  study  of  local  anaesthesia  has  made  such 
great  progress  recently,  and  has  led  to  so  great  an 
improvement  and  perfecting  of  methods,  that  it 
seems  desirable  that  it  should  be  still  more  widely 
employed  by  medical  practitioners  than  has 
hitherto  been  the  case.  Only  in  the  last  year  or 
two  has  it  begun  to  figure  at  all  frequently  as  an 
item  of  any  importance  in  the  clinical  curriculum, 
a  change  which  will  be,  I  think,  of  material  advan- 
tage to  the  present  generation  of  students. 
^  The  chief  aim  of  this  book  is  to  enable  those 
who  have  no  opportunity  to  gain  acquaintance 
with  the  various  methods  by  observing  them  in 
actual  practice,  to  perfect  themselves  in  technique 
by  proceeding  gradually  from  the  simpler  to  the 
more  difficult  tasks.  In  the  second  place,  I  have 
endeavoured  to  describe,  in  accordance  with  the 
present  state  of  our  knowledge  and  for  the  benefit 
of  specialists,  the  best  methods  of  dealing  with 
those  more  difficult  tasks. 

Comparatively  little  space  has  been  given  to 
expositions   of  theory.     These    are,   however,   so 


vi  PREFACE 

important  for  a  right  understanding  of  the  subject 
that  due  consideration  should  always  be  given  to 
them,  especially  as,  owing  to  the  very  rapid 
development  of  our  subject,  many  divergences  of 
opinion  have  arisen.  I  have  avoided  detailed 
references  to  the  literature,  but  have  everywhere 
named  the  more  important  authorities. 

As  regards  technique,  I  have  throughout  en- 
deavoured to  put  before  my  readers  what  I  have 
found  by  experience  to  be  the  simplest  and  most 
practical  methods.  Where  new"  and  as  yet  un- 
proved methods  are  cited,  the  fact  is  always  made 
clear  in  the  text. 

I  have  to  render  cordial  thanks  to  Privatdozent 
Dr.  Haike  and  to  Dr.  Fehr,  Surgeon  to  the 
Yirchow  Hospital ;  to  the  former  for  assistance 
in  the  preparation  of  the  section  on  aural  and 
nasal  operations,  and  to  the  latter  for  similar  help 
in  dealing  with  operations  on  the  eye. 

THE  AUTHOR. 


CONTENTS 


PAGE 

PREFACE  .  .  .  .  .  .V 

CHAPTER 

I.   HISTORICAL    SURVEY  ....  1 

II.   PHYSICAL   PRINCIPLES  .  .  .  .13 

III.  LOCAL  ANESTHETICS  .  .  .  .18 

COCAIN   AND    ITS    SUBSTITUTES  .  .  .19 

SUBSTANCES  WHICH   PRODUCE  AN  ANESTHETIC 

EFFECT   BY   MEANS    OF   COLD  .  .19 

IV.  ADJUVANTS   IN    LOCAL   ANESTHESIA  .  .         37 

1.  COLD  .  .  .  .  .38 

2.  ANEMIA  :   PRODUCED —  .  .  .40 

(a)   BY   CONSTRICTION  .  .  .40 

(5)   BY   INFILTRATION   (SCHLEICH).  .         41 

(c)   BY   SUPRARENAL   PREPARATIONS  .         42 

V.    METHODS    OF    LOCAL    ANESTHESIA    AND    THEIR    AP- 
PLICATION .  .  .  .52 

1.  ANESTHESIA   PRODUCED   BY   COLD    .  .         52 

2.  ANESTHETIZATION   OF   SURFACES       .  .54 

3.  SCHLEICH'S    INFILTRATION   ANESTHESIA         .         56 

4.  ANESTHESIA  BY  INTERRUPTION  OF  SENSORY 

CONDUCTION    ("NERVE    BLOCKING  ")  .         63 

5.  VENOUS  ANESTHESIA  .  .  .68 
ARTERIAL  ANESTHESIA           .                .  .74 

vii 


Vlll 


CONTENTS 


CHAPTER 

VI.    GENERAL  TECHNIQUE  .  .  .  . 

VII.  METHODS  FOR  ANESTHETIZING  THE  SKIN  AND  THE 
DIFFERENT  TISSUES — PROCEDURE  IN  CERTAIN 
DISEASED    CONDITIONS— CIRCULAR   ANALGESIA 

VIII.    OPERATIONS    ON   THE   HEAD 

1.  OPERATIONS  ON  THE  SCALP  AND  FOREHEAD 

2.  OPERATIONS   ON   THE   FACE  . 

3.  OPERATIONS   ON   THE   EAR    . 
OPERATIONS     ON     THE     NASAL    AND     ORAL 

CAVITIES  .... 
OPERATIONS   ON   THE   EYE    . 

IX.   OPERATIONS   ON   THE   CERVICAL   REGION      . 

X.   OPERATIONS   ON   THE   THORAX 

XI.   OPERATIONS   ON   THE   EXTREMITIES 

XII.   ABDOMINAL   OPERATIONS     . 
nERNIA   OPERATIONS    . 

XIII.   O.'ERATIONS     ON     THE    ANAL     REGION     AND     THE 
GENITO-URINARY  TRACT 


PAGE 

75 


93 

105 
105 
110 
111 

119 
123 

145 

153 

157 

175 
184 

193 


INDEX 


203 


LOCAL  ANiESTHESIA 

CHAPTEE  I 

HISTORICAL  SURVEY 

The  endeavour  to  render  operations  painless  by 
inducing  local  ansesthesia  is  almost  as  old  as 
medicine  itself.  From  the  most  ancient  times 
physicians  have,  in  addition  to  their  attempts  to 
carry  out  operations  painlessly  by  some  method  of 
dulling  the  sensor ium,  endeavoured  also  by  some 
locally  acting  agent  to  secure  anaesthesia  or  the 
actual  site  of  operation. 

The  different  ways  in  which  this  end  was  sought 
to  be  attained  may  here  be  briefly  reviewed. 

Leaving  out  of  account  the  experiments  men- 
tioned by  ancient  writers,  with  crocodile  fat,  dried 
and  powdered  crocodile  skin,  friction  with  vinegar 
and  stone  of  Memphis,  and  so  on,  we  may  regard 
as  the  earliest  scientific  method — 

1.  The  Production  of  Aiiwsthesia  hy  Compression 
of  Nerves. — In  very  early  times,  and  later  among 
the  Arabs,  the  method  of  nerve  compression  by  liga- 


2  LOCAL  ANESTHESIA 

turing  the  extremities  was  practised  with  a  view 
to  the  production  of  local  anaesthesia.  Since  then 
the  method  has  been  again  and  again  "re-dis- 
covered," only  to  be  again  abandoned  on  account 
of  its  imperfections.  At  the  beginning  of  the 
nineteenth  century  it  was,  according  to  Desault, 
in  frequent  use.  Quite  recently  the  method  has 
been  once  more  "  discovered  "  by  Kofmann.  While, 
however,  the  earlier  authorities  regarded  the  nerve 
compression  brought  about  by  ligaturing  the 
extremities  as  the  anaesthesia-producing  agent, 
Kofmann  held  that  the  anaesthesia  was  caused 
by  the  bloodless  condition  of  the  limb  due  to  the 
ligature.  Braun's  experiments  have  proved  finally 
that  ligature  owes  such  power  as  it  possesses  to 
diminish  pain  solely  to  the  compression  of  nerves 
caused  by  it. 

2.  Cold  as  an  anaesthetic  agent  was  first  em- 
ployed in  the  sixteenth  century  by  Marcus  Aurelius 
Severinus,  who  simply  placed  pieces  of  ice  upon 
the  part  to  be  anaesthetized.  Much  later  the 
anaesthetic  action  of  cold  was  again  learnt  in  the 
Napoleonic  campaigns  in  Russia  [Larrey),  when, 
as  for  instance  after  the  Battle  of  Eylau,  it  was 
found  that  limbs  benumbed  by  cold  could  be  ampu- 
tated without  pain.  After  this  Hunter,  and  later 
(1849)  Arnott,  employed  freezing  mixtures  for  the 
production  of  local  anaesthesia.  A  few  years  later, 
again,  sulphuric  ether  was  employed  by  Bochet, 


HISTORICAL  SURVEY  3 

the  method  at  first  adopted  being  to  allow  the 
ether  to  drop  slowly  upon  the  skin  and  evaporate. 
It  was  not,  however,  until  1866  that  Richardson 
furnished,  in  his  well-known  and  still  widely  used 
ether  spray  apparatus,  a  really  practical  means 
for  the  utilization  of  the  volatile  properties  of 
ether. 

The  substances  which  have  since  that  time  been 
introduced  as  substitutes  for  ether,  to  be  applied 
by  means  of  the  spray  apparatus,  such  as  brom- 
ethyl,  ethylene  chloride,  etc.,  have  not  all  succeeded 
in  securing  any  wide  adoption.  The  introduction 
of  ethyl  chloride  constituted  the  first  notable  ad- 
vance, inasmuch  as  its  applicability  was  indepen- 
dent of  the  surrounding  temperature.  At  all 
ordinary  room  temperatures  the  chloride  of  ethyl 
is  gaseous,  and  can  only  be  kept  in  the  liquid  state 
under  pressure.  The  time  required  to  freeze  the 
skin  is,  by  the  use  of  ethyl  chloride,  notably 
diminished. 

The  newer  substances  of  still  lower  boiling-point 
than  ethyl  chloride  {methyl  chloride,  ancesthyl, 
metethyl,  koryl,  etc.)  have  not  been  much  used, 
the  danger  of  injury  to  the  tissues  increasing  with 
the  rapidity  of  action  of  the  evaporating  agent. 

Equally  little  practical  success  has  attended 
attempts  to  employ  ethyl  chloride  or  ether  to  act 
upon  deep  structures  such  as  nerve-trunks  {Boss- 
bach,  Sc heller,  von  Hacker). 


4  LOCAL  ANESTHESIA 

3.  As  regards  other  purely  physical  methods,  it 
may  be  stated,  merely  as  a  matter  of  historical 
interest,  that  in  the  'fifties  of  the  last  century  the 
electric  current  was  warmly  extolled  as  a  local 
anaesthetic  agent,  and  that  the  claims  made  for  it 
proved  to  be  quite  unjustified.  It  is  possible  that 
results  of  practical  utility  may  eventually  be 
attained  by  the  use  of  rhythmic  intermittent 
currents  (the  so-called  Le  Due's  currents).  Re- 
peated experiments  by  the  author  have  had  nega- 
tive results.  At  the  same  time,  the  fact  that 
with  these  currents  one  can  obtain  at  any  rate 
a  diminution  of  sensibility,  e.g.,  in  the  finger 
(one  electrode  on  the  median  nerve  and  the 
other  around  the  base  of  the  finger),  shows  that 
the  prospect  of  some  further  practical  advance 
in  this  direction  is  not  to  be  summarily  dis- 
missed. 

Other  physical  conditions — osmotic  differences, 
drying  or  infiltration  of  tissues,  etc. — play,  as  we 
shall  see,  a  certain  r61e  as  auxiliaries  in  the  pro- 
duction of  local  anaesthesia. 

4.  Finally,  attempts  to  produce  local  anaesthesia 
by  chemical  means  can  also  be  traced  back  to 
ancient  times.  In  this  connection  the  impetus  to 
investigation  has  almost  always  been  given  by  the 
idea  that  substances  which  produce  a  general 
deadening  of  sensibility  must,  if  applied  to  some 
special  part,  exert  there  also  a  sedative  influence. 


HISTORICAL  SURVEY  5 

Thus  the  Egyptians,  the  Greeks,  and,  later,  the 
Romans  employed  the  poppy,  Indian  hemp,  hen- 
bane, mandrake-root,  and  mandragora,  as  local 
anaesthetics.  The  same  conception  governed  the 
practice  of  the  Middle  Ages.  Plasters  and  poultices 
containing  the  substances  named  were  applied  to 
the  site  of  operation  by  medieval  physicians, 
while  the  ancients  generally  employed  sponges 
soaked  in  the  juice  of  the  selected  plant.  As  late 
as  the  middle  of  the  nineteenth  century  Bouisson 
stated  that  he  could  produce  anaesthesia  of  a  toe 
by  applying  opium  compresses. 

When  the  general  anaesthetic  properties  of  ether 
and  chloroform  were  discovered,  these  substances 
also  came  into  use  for  the  production  of  local 
anaesthesia.  Richardson  and  Aran  believed  that 
local  anaesthesia,  as  well  as  general  narcosis, 
depended  on  abstraction  of  water.  Later,  again, 
Tiirck  and  Scheif  employed  local  applications  of 
chloroform,  solutions  of  morphine  salts,  etc.,  for 
the  anaesthetization,  for  instance,  of  the  laryngeal 
mucous  membrane.  All  these  experiments  were 
quite  without  practical  result.  The  ever  new 
recommendations,  however,  of  substances  and 
methods  show  how  great  is  the  power  of  sugges- 
tion in  the  whole  matter.  The  recommendations 
are,  of  course,  made  for  the  most  part  in  good  faith, 
but  the  optimism  of  operators  and  variations  in 
the  degree  of  sensibility  to  pain  in  their  patients 


6  LOCAL  ANAESTHESIA 

have  been  very  fruitful  sources  of  fallacy  in  these 
experiments. 

Again,  after  the  discovery  of  the  method  of 
hypodermic  injection  by  Wood  in  1853,  the  local 
anaesthetic  power  of  morphia  and  chloroform  was 
tested  by  this  method,  in  the  latter  case  with  the 
result  that  the  pain  of  the  injection  often  greatly 
exceeded  that  of  the  operation  itself 

Of  other  sedative  substances  and  methods  which 
have  been  experimented  with  and  recommended, 
mention  may  be  made  of  hydrocyanic  acid 
{Simpson),  carbonic  acid  externally  applied  [Perci- 
val,  1772),  and  saponin  hypodermically  injected 
(Pelikan). 

The  question  of  the  production  of  local  insensi- 
bility to  pain  acquired  an  altogether  greater 
practical  importance  with  the  commencement  of 
our  knowledge  of  the  local  ansesthetic  pro]3erties 
of  cocain.  Leaves  of  the  coca-plant  were  brought 
to  Germany  by  Scherzer  from  South  America, 
where  their  partly  stimulating  and  tonic  and 
partly  sedative  effects  had  long  been  known.  In 
several  German  laboratories  investigations  were 
made  with  a  view  to  the  discovery  of  the  true 
active  principle  of  the  plant.  At  first  it  was 
thought  that  this  had  been  discovered  in  a  body 
to  which  the  name  erythroxylin  was  given.  Later, 
however,  the  claims  of  this  body  were  entirely 
thrust  aside  in  favour  of  those  of  a  substance  dis- 


HISTOEICAL  SURVEY  7 

covered  in  Woehler's  laboratory  by  Niemann  and 
Lossen  in  1860,  and  named  by  them  cocain. 

Twenty  years  elapsed  before  the  knowledge  of 
the  anaesthetic  properties  of  the  substance  spread 
sufficiently  widely  in  the  medical  profession  to 
lead  to  the  resolve  to  test  its  applicability  to 
operative  surgery.  Its  results  in  ophthalmic 
operations  were  first  reported  on  in  1884  by 
Roller,  and  soon  after  this  followed  its  use  as  a 
locally-applied  anaesthetic  in  operations  on  the 
nose  and  larynx. 

In  1885  the  first  monographs  on  the  use  of 
cocain  hypodermically  in  surgical  operations  ap- 
peared almost  simultaneously  in  Germany,  the 
United  States,  and  Austria  {Landerer,  Corning, 
Woelfler).  The  most  important  of  these  papers 
is  that  of  Corning,  which  establishes  two  signifi- 
cant facts  :  (1)  The  heightened  effect  of  cocain 
in  tissues  emptied  of  blood,  and  the  consequent 
possibility  of  obtaining  satisfactory  results  by  the 
injection  of  very  dilute  solutions  ;  (2)  the  possi- 
bility of  interrupting  conduction  in  sensory  nerves 
by  cocain  injections,  an  observation  which  formed 
the  foundation  of  the  method  of  conduction- 
ancestliesia,  later  to  become  so  fruitful  in  good 
results. 

In  general,  the  method  adopted  in  these  early 
times  of  cocain  anaesthesia  was  to  inject  certain 
quantities   of  1    to   5   per   cent,   solutions  in  the 


8  LOCAL  ANESTHESIA 

neighbourhood   of  the  site   of  operation   and    to 
wait  for  their  diffusion. 

It  was  the  French  surgeon,  E-eclus,  who  w^as 
the  first — in  the  late  eighties  of  last  century — to 
make  any  extended  use  of  cocain  injections  for  the 
production  of  local  ana3sthesia.  He  employed  at 
first  5  per  cent.,  later  1  per  cent,  and  J  per  cent, 
solutions,  and  performed  with  their  aid  a  very 
large  number  of  operations  on  the  genito-urinary 
organs  and  the  anus.  We  cannot,  in  the  light  of 
our  present  knowledge,  assent  when  he  describes 
his  methods  as  free  from  risk.  His  maximal  dose 
of  0'2  gramme  (3*08  grains)  injected  in  1  per 
cent,  solution  is  undoubtedly  much  too  large — 
so  dangerous,  indeed,  in  my  opinion,  that  one  is 
almost  forced  to  conclude  that  the  preparations 
employed  by  him  were  different  from  those  used 
nowadays. 

The  credit  of  devising  a  technique  satisfying 
the  first  demand  one  is  entitled  to  make  of  any 
method  for  producing  local  anaesthesia — namely, 
that  it  shall  be  safe  and  thus  freely  utilizable — 
belongs  undoubtedly  to  the  Berlin  surgeon, 
Schleich.  For  a  long  time  past  a  Schleich-Reclus 
"  infiltration  anaesthesia  "  has  been  spoken  of.  It 
is  certain,  however,  that  the  method  to  which 
Schleich  gave  that  name,  with  its  production  of  a 
local  oedema  and  its  small  dose  of  cocain,  differs 
in   principle    from    any    that    preceded    it.      The 


HISTORICAL  SURVEY  9 

method  of  rendering  the  skin  itself  insensitive  by 
injecting  in  such  a  manner  as  to  form  wheals 
{ Qaaddel )  wSiS  desQrihed  by  Roberts  before  Eeclus 
or  Schleich  wrote  on  the  subject. 

Schleich's  discovery  was  greeted  with  much 
scepticism  when  first  demonstrated  before  the 
Surgical  Congress  in  1892.  The  method  gradually 
made  its  way,  however,  and  was  for  some  years 
almost  the  sole  method  in  general  use.  In  spite 
of  the  improvements  in  technique  made  since  that 
time,  it  will  probably  never  be  abandoned  alto- 
gether, but  will  be  employed  from  time  to  time  in 
specially  suitable  cases. 

Side  by  side  with  this  method  of  tenninal  ances- 
thesia,  in  which  the  sensory  nerve-endings  in  the 
area  of  operation  itself  are  acted  upon  by  anaes- 
thetic solutions,  another  method  has  been  evolved 
which  has  gradually  surpassed  it  in  importance,  a 
method  which,  following  Braun,  we  name  regional 
or  conduction  ancesthesia.  In  this  method  the 
actual  site  of  operation  is  left  uninterfered  with, 
but  the  conduction  of  sensory  impulses  therefrom 
is  interrupted  by  injections  into  the  neighbourhood 
of  the  nerve-trunks  supplying  it.  The  originator 
of  this  method  is  the  American,  Corning,  who, 
in  1887,  by  means  of  injections  around  the 
N.  cutaneus  antebrachii,  produced  an  anaesthesia 
of  the  cutaneous  area  supplied  by  that  nerve. 
The  method  remained  of  little  importance  in  prac- 


10  LOCAL  ANESTHESIA 

tice  until  1890,  when  Oberst  and  Pernice,  who 
were  unacquainted  with  Coming's  experiments, 
rendered  a  finger  anaesthetic  by  ligaturing  the 
base  and  injecting  the  neighbourhood  of  the  nerve- 
trunks  in  which  ran  the  finger's  sensory  fibres. 

A  further  step  forward  was  Hackenbruch's 
circular  analgesia.  In  this  method  injections  of 
anaesthetic  solutions  are  made  all  round  the  site 
of  operation,  the  conduction  of  the  sensory  im- 
pulses therefrom  being  thus  entirely  interrupted. 
Hackenbruch  employed  a  solution,  consisting  of 
equal  parts  of  J  per  cent,  solutions  of  cocain  and 
eucain. 

In  Oberst  s  method  the  injections  are  made 
perineurally,  and  the  solutions  reach  the  nerves 
themselves  by  diftusion.  Krogius  has  suggested 
endoneural  injections,  but  the  method  has  as  yet 
little  practical  importance.  The  perineural 
method,  on  the  other  hand,  has  been  widely  de- 
veloped. Hall  applied  it  to  the  infra-orbital  nerve, 
Hallstedt  to  the  inferior  alveolar,  and  Manz  to  the 
larger  nerve-trunks  in  the  hand  and  foot.  It  is 
to  Braun,  however,  who  in  his  textbook  of  local 
ana3sthesia,  published  in  1905,  gives  detailed 
descriptions  of  technique  applicable  to  every 
region  of  the  body,  that  credit  is  chiefly  due  for 
the  development  of  the  method.  Braun's  later 
work  has  been  chiefly  devoted  to  a  confutation  of 
Schleich's    views,    according    to    which    physical 


HISTORICAL  SURVEY  11 

factors — osmotic  tension,  oedema,  pressure — play 
the  chief  part  in  producing  anaesthesia,  the  anaes- 
thetic itself  having  only  a  secondary  role.  We 
have  to  thank  Braun,  also,  for  another  notable 
advance — the  introduction  of  preparations  from  the 
suprarenal  gland,  which,  injected  with  the  anaes- 
thetic, lessen  the  risk  of  poisoning  and  at  the 
same  time  increase  the  local  effect. 

Important  progress  has  been  made  during  the 
last  few  years  in  another  direction.  Experimental 
chemistry  has  furnished  us  with  substitutes  for 
the  poisonous  cocain,  which,  while  considerably 
less  toxic  than  that  substance,  are  not  markedly 
less  effective  as  anaesthetics.  Among  these  novo- 
cain has,  in  consequence  of  its  combining  high 
anaesthetic  efficiency  with  low  toxic  power,  come 
very  rapidly  into  general  use,  and  is  employed 
now  by  the  majority  of  surgeons.  So  far,  indeed^ 
has  this  displacement  of  cocain  by  less  toxic  sub- 
stitutes advanced  that  Bier  was  justified  in  saying 
at  the  Surgical  Congress  of  1909  that,  except  for 
operations  on  the  mucous  membranes  and  the  eye, 
cocain  ought  no  longer  to  be  used.  Another 
advance  we  owe  to  chemical  industry  is  the 
synthetic  production,  a  few  years  ago,  of  the  bodies 
to  which  suprarenal  preparations  owe  their 
efficacy. 

The  latest  development  to  which  we  would 
draw  attention,  as  it  opens  up  a  new  field  for  local 


12  LOCAL  ANESTHESIA 

anaesthesia,  is  the  introduction  of  Bier's  venous 
aiiwsthesia,  in  which  J-  per  cent,  solution  of  novo- 
cain is  injected  into  a  vein  between  two  Esmarch's 
tourniquets  appHed  to  the  arm  or  leg.  An 
anaesthesia  is  produced  in  this  way  which  is  fully 
sufficient  for  the  performance  of  major  operations, 
such  as  resections  or  amputations,  between  the 
two  ligatures,  or  at  any  point  peripheral  to  them. 


CHAPTEP.  II 
PHYSICAL   PEINCIPLES 

If  we  inject  some  ordinary  tap-water  underneath 
the  human  epidermis  into  the  cutis  (endermal 
injection),  a  whitish  weal  is  produced,  somewhat 
resembhng  that  caused  by  the  sting  of  an  insect ; 
at  the  same  time  fairly  acute  pain  is  felt,  and  this 
is  followed  later  by  an  ansesthetic  condition 
hmited  to  the  area  of  the  weal.  This,  too, 
gradually  passes  away. 

The  cause  of  the  pain  and  of  the  subsequent 
anaesthesia  is  as  follows  : 

If  we  have  in  a  vessel  two  solutions  of  the  same 
salt,  but  of  different  concentrations,  whether 
separated  by  a  permeable  membrane  or  not,  an 
exchange  of  molecules  will  take  place  between  the 
two  :  molecules  of  the  salt  will  pass  from  the 
more  concentrated  to  the  more  dilute  solution, 
while  molecules  of  water  pass  simultaneously  in 
the  opposite  direction.  This  exchange  proceeds, 
if  both  solutions  are  of  the  sanie  salt,  until  the 
solution  is  of  the  same  concentration  throughout. 
Before  diffusion  there  is  a  condition  of  so-called 

13 


14  LOCAL  ANESTHESIA 

"  osmotic  tension "  between  the  two  solutions. 
The  more  concentrated  solution  is  said  to  be 
"  hypertonic  "  the  more  dilute  "  hypotonic."  After 
diffusion  we  have  an  ''  isotonic "  condition,  in 
which  the  solution  presents  the  same  molecular 
concentration  throughout.  If  the  salts  in  the  two 
solutions  are  not  identical,  then,  for  each  concen- 
tration of  the  one  solution,  a  certain  definite  con- 
centration of  the  other  is  required  to  bring  about 
the  isotonic  condition,  in  which  no  exchange  of 
molecules,  whether  of  salts  or  of  solvent,  takes 
place.  The  simplest  method  for  estimating  osmotic 
tension  is  the  determination  of  the  freezing-point 
of  the  solution  dealt  with.  Isotonic  solutions 
have  the  same  freezing-point ;  in  hyperosmotic 
(hypertonic)  solutions  the  freezing-point  is  lower, 
in  hyposmotic  (hypotonic)  solutions  it  is  higher. 

If,  now,  we  apply  the  foregoing  to  our  chosen 
example,  we  have,  after  injection  of  water  into  the 
cutis,  an  exchange  of  molecules,  for  the  reason 
that  the  lymph  or  blood  flowing  through  the 
tissues  has  a  relatively  high  saline  content,  and 
is  therefore  hypertonic  to  water,  so  that  saline 
particles  pass  from  the  blood  and  lymph  to  the 
injected  water,  and,  on  the  other  hand,  water 
diffuses  itself  through  the  tissues,  producing  a 
sodden  or  soaked  condition  (Quellung).  This 
soaking  of  the  tissues  is  the  cause  of  the  phe- 
nomena we  observe.     It  irritates  the  sensory  nerve- 


PHYSICAL  PRINCIPLES  15 

endings,  thus  causing  pain  (Quellungsschmerz), 
which  is  followed  by  a  condition  of  anaesthesia 
(Quellungsanclsthesie,  Braun).  Injection  of  con- 
centrated solutions,  in  consequence  of  the  abstrac- 
tion of  water  it  brings  about,  also  causes,  though 
in  a  slightly  different  way,  pain  with  subsequent 
anaesthesia. 

The  anaesthesia,  preceded  by  pain,  which  is 
caused  by  injections  of  water  is  named,  after 
Liebreich, ''  anaesthesia  dolorosa."  It  is  not  a  suit- 
able method  for  producing  local  anaesthesia  in 
actual  practice,  for  the  reason  that  the  injection 
of  substances  markedly  hypotonic  to  the  tissue 
fluids,  apart  from  the  pain  it  produces,  actually 
injures  the  tissues,  as  is  proved  by  the  frequent 
occurrence  of  necrosis  after  injections  of  water 
[Braun).  If  common  salt  is  added  to  the  water 
injected,  it  is  found  that  both  the  pain  and  the 
subsequent  anaesthesia  diminish  as  the  concentra- 
tion of  the  solution  increases,  and  a  point  is  finally 
reached  at  which  the  salt  solution  (0*9  per  cent.,  or 
"physiological"  salt  solution)  causes  neither  pain 
nor  anaesthesia.  The  freezing-point  of  the  tissue 
fluids  is,  at  this  point,  the  same  as  that  of  the 
salt  solution.  If  we  now  carry  the  concentration 
of  the  salt  solution  further,  the  phenomena  of  pain 
and  subsequent  anaesthesia  are  again  elicited. 
They  are,  however,  to  be  ascribed  now,  not  to  the 
soaking  of  the  tissues,  but,  on  the  contrary,  to 


16  LOCAL  ANESTHESIA 

their  beiDg  drained  of  fluid  {Braun).  We  have, 
then,  in  physiological  salt  solution,  a  combination 
which  neither  causes  pain  when  injected,  nor 
injures  the  tissues,  and  constitutes,  therefore,  an 
ideal  vehicle  for  anaesthetizing  substances. 

The  absence  of  either  "  soakage  "  or  "  drainage  " 
anaesthesia  is  of  little  importance  in  view  of  the 
pain -deadening  power  of  the  substances  we  employ 
as  local  anesthetics. 

We  require  of  the  anaesthetic  itself,  no  less  than 
of  the  vehicle  in  which  it  is  dissolved,  that  its 
injection  shall  be  free  from  pain,  and  shall  not 
cause  injury  to  the  tissues.  Braun  and  Heinze 
have  tested  a  large  number  of  substances  by 
Schleich's  method,  and  have  found  very  few  which 
meet  our  requirements  fully  in  these  respects. 
Those  which  do  so,  and  are  therefore  suitable  for 
use  as  local  anaesthetics,  exert  their  anaesthetic 
powers,  when  injected  endermally,  in  very  dilute 
solutions. 

The  method  of  testing  an  anaesthetic  by  injecting 
it  so  as  to  form  weals  is,  however,  only  valid  if 
the  object  for  which  we  wish  to  employ  the  sub- 
stance tested  is  the  production  of  anaesthesia  of 
the  skin  or  mucous  membrane.  Other  laws 
come  into  operation  where  diffusion  through 
several  tissues  is  in  question,  as,  for  instance, 
when  a  mucous  membrane  is  rendered  insensitive 
by  external  application  of  the  anaesthetic. 


PHYSICAL  PRINCIPLES  17 

Thus  tropacocain,  which  is  quite  useless  for  the 
production  of  infiltration  anaesthesia,  is  used  by 
many  ophthalmologists  for  subconjunctival  instil- 
lation. 

The  laws  of  diffusion  apply,  of  course,  as  fully 
to  endermal  as  to  hypodermic  injection.  Of 
special  importance  here  is  the  fact  that  concen- 
trated solutions,  after  injection,  continue  to  take 
up  water  from,  and  give  up  their  salts  to,  the 
tissues,  until  a  condition  of  osmotic  equilibrium 
obtains.  We  can  thus,  by  injecting  a  concen- 
trated solution  of  an  anaesthetic  merely  into  the 
neighbourhood  of  an  organ  such  as  a  nerve,  secure, 
by  means  of  the  diffusion  process  set  up,  the 
gradual  passage  of  the  anaesthetic  into  the  nerve 
itself. 


CHAPTER  III 
LOCAL  ANESTHETICS 

Though,  as  we  have  stated  above,  cocain  itself  is 
no  longer  widely  used,  it,  nevertheless,  as  the  first 
of  modern  local  anaesthetics,  and  the  one  from 
which  nearly  all  those  in  common  use  to-day  may 
be  said  to  have  been  derived,  deserves  special 
and  prior  mention  and  consideration. 

Cocain,  an  alkaloid  obtained  from  the  leaves  of 
the  coca-plant,  was  first  isolated  by  Niemann  and 
Lossen  in  Wohler's  laboratory.  Later  it  was  pro- 
duced synthetically.  Commercial  hydrochlorate 
of  cocain  of  the  present  day  is  a  white  powder 
freely  soluble  in  water  and  alcohol.  It  is  odourless, 
but  has  a  bitter  taste.  The  nature  of  the  local 
action  of  cocain  has  been  a  subject  of  prolonged 
controversy.  It  was  formerly  held  that  it  acted 
by  virtue  of  its  power  to  produce  anaemia,  as  it  is 
known  to  cause  contraction  of  the  smaller  blood- 
vessels and  capillaries.  This  anaemia  certainly 
plays  a  part  in  cocain  anaesthesia,  which  we  shall 
consider  later  ;  the  actual  anaesthetic  effect,  how- 
ever, depends  on  a  purely  chemical  action,  on  an 

18 


LOCAL  ANiESTHETIGS  19 

affinity  between  the  drug  and  the  protoplasm  of 
the  tissues,  which  gives  rise  to  a  chemical  combina- 
tion, of  whose  exact  composition  we  are  at  present 
ignorant.  That  the  anaemia  is  not  the  efficient 
cause  of  the  anaesthesia  is  proved  by  the  following 
facts  : 

1.  Gocain  has  been  found  to  produce  its  anaes- 
thetic effect  even  when  the  blood  in  the  vessels 
has  been  replaced  by  salt  solution. 

2.  There  is  a  whole  series  of  preparations  which 
are  efficient  producers  of  local  anaesthesia,  but  do 
not  cause  simultaneous  anaemia — e.g.,  eucain. 

The  aqueous  solutions  of  cocain  which  were  in 
general  use  until  the  introduction  of  the  modern 
substitutes  are  all  strongly  hyposmotic  or  hypo- 
tonic. Their  freezing-point  varies,  according  to 
Braun,from  0*02°  (O'l  percent,  solution)  to  0*11 5^0. 
(1  per  cent,  solution),  the  freezing-point  of  human 
blood  being  about  0*55°  C  Their  injection,  never- 
theless, causes  no  "infiltration  pain"  (Quellungs- 
schmerz),  as  this  is  overborne  by  the  essential 
anaesthetic  effect  of  the  drug. 

Different  kinds  of  protoplasm  have  different 
degrees  of  chemical  affinity  for  cocain ;  what  chiefly 
concerns  us  is  the  high  degree  of  affinity  in  the 
case  of  the  sensory  nerves.  Thus,  according  to 
Braun,  a  0*005  per  cent,  solution  of  cocain  injected 
so  as  to  produce  a  weal  is  sufficient  to  deaden  for 
a  short  time  the  sensory  nerve-endings  within  the 


20  LOCAL  ANESTHESIA 

weal.  By  this  property  of  acting  in  very  dilute 
solutions  cocain  and  its  derivatives  are  clearly  dis- 
tinguished from  a  whole  series  of  other  substances 
which  act  as  anaesthetics  when  injected,  but  all 
belong  more  or  less  to  the  group  of  ancesthetica 
dolorosa,  and,  being  consequently  of  no  practical 
value,  need  not  be  enumerated  here. 

It  is  important  to  remember  that  tactile  and 
pressure  sensations  are  diminished  by  cocain  later 
and  in  less  degree  than  sensations  of  pain.  Thus 
it  often  happens  that  patients  in  whom  sensibility 
to  pain  has  been  entirely  removed  at  the  site  of 
operation  will  be  conscious  of  the  pressure  of  the 
surgeon's  knife,  or  of  the  drawing  apart  of  the 
edges  of  the  wound,  and  this  may  lead  in  nervous 
and  excitable  patients  to  failure,  or  comparative 
failure,  if  sufficient  time  be  not  allowed  for  the 
anaesthetic  to  produce  its  full  effect  on  sensation. 
The  senses  of  smell  and  taste  are  also  inhibited 
by  cocain,  but  here,  too,  later  than  sensations  of 
pain. 

The  motor  nerves  are  much  less  affected — so  little, 
in  fact,  that  the  effect  of  cocain  upon  them  is  as 
a  rule  practically  negligible.  It  is  only  in  the 
so-called  venous  ancesthesia  that  motor  paralysis 
serves  to  announce  the  commencement  of  anaes- 
thesia. The  greatest  sensitiveness  to  the  action 
of  cocain  is,  however,  exhibited  by  the  central 
nervous   system.     If,  over  and  above  the  cocain 


LOCAL  ANESTHETICS  21 

remaining  and  acting  at  the  site  of  injection,  any 
considerable  quantity  of  the  drug  should  make  its 
way  into  the  general  circulation,  symptoms  refer- 
able to  the  brain  and  spinal  cord  will  be  the  first 
to  manifest  themselves,  cardiac  symptoms  being 
the  next  in  order  of  appearance. 

Cocain-poisoning  was,  not  so  very  long  ago,  a 
factor  of  considerable  importance  in  local  anaes- 
thesia, and  though,  fortunately,  it  now  rarely 
comes  under  our  notice,  some  consideration  of  its 
symptoms  and  prophylaxis  will  help  towards  a 
clear  understanding  of  the  whole  subject  of  local 
anaesthesia  ;  such  consideration  is  called  for,  also, 
in  view  of  the  fact  that  cocain  is  still  freely  used 
both  by  ophthalmologists  and  dental  surgeons. 

In  acute  cocain-poisoning  (with  which  alone  Ave 
have  here  to  do)  the  patient  is  seized,  almost  im- 
mediately after  the  injection,  w^ith  giddiness,  which 
in  severe  cases  passes  on  to  a  condition  of  syncope  ; 
palpitation  is  generally  present  ;  the  face  is  pale, 
the  pulse  small  and  rapid ;  as  a  rule  the  patient 
feels  anxious  and  oppressed,  with  a  sensation  of 
tightness  across  the  chest.  The  whole  symptom 
complex  may  be  referred  in  part  to  contraction  of 
the  cerebral  bloodvessels,  in  part  to  a  specific 
action  on  the  cerebral  cortex. 

In  the  milder  cases  the  patient  recovers  after  a 
few  seconds  or  minutes  ;  in  the  more  severe  the 
dominating  feature  is  a  condition  of  excitement 


22^  LOCAL  AX^ESTHESIA 

resembling  in  some  resjDects  that  due  to  alcoholic 
intoxication.  In  fatal  cases  death  due  to  paralysis 
of  the  resjDiratory  centre  is  ushered  in  by  convul- 
sions and  coma.  In  severe  cases  which  do  not  end 
fatally  the  patient  exhibits  extreme  excitement,  and 
talks  volublv  like  a  slio-htlv  drunken  man.  There 
is  generally  marked  anxiety,  with  dryness  of  the 
throat  and  tingling  or  numbness  in  the  extremities  ; 
the  pupils  are  dilated  and  fixed.  In  most  non- 
fatal cases  recovery  is  rapid  ;  occasionally,  how- 
ever, a  condition  of  debility  supervenes  which  lasts 
for  a  considerable  time. 

Of  the  very  first  importance  in  connection  with 
the  causation  of  cocain-poisoning  is  the  fact,  estab- 
lished clinically  by  Schleich,  and  experimentally 
by  Maurel,  that  a  qiven  dose  of  cocain  which,  injected 
in  concentrated  solution,  will  give  rise  to  severe  toxic 
symptoms^  may  he  quite  tcell  borne  if  giveii  in  a  dilute 
solution.  The  maximum  dose  of  cocain  is  often 
given  as  0*05  gramme  (Ov7  grain).  Such  a  state- 
ment is  entirely  futile.  I  can  inject  twice  that 
dose  in  a  O'l  per  cent,  solution  without  risk, 
whereas  a  fraction  thereof  in  a  5  per  cent,  solution 
may  produce  most  alarming  symptoms  of  poison- 
ing, or  even  cause  death.  It  requires  a  very  short 
time  to  produce  cocain-poisoning  when  cocain,  in 
solutions  over  and  above  a  certain  concentration, 
reaches  the  blood-stream. 

The    explanation   of   this  fact  put  forward  by 


LOCAL  ANESTHETICS  23 

Schleich  is  that  around  the  small  ischsemic 
oedematous  area,  where  the  small  quantity  of 
concentrated  solution  lies  deposited,  a  collateral 
hypersemia,  with  increase  of  blood-pressure,  is 
established,  which,  by  causing  pressure  from 
without,  forces  the  cocain  into  the  lymph  channels, 
whereas,  where  a  larger  deposit  of  more  dilute 
solution  is  in  question,  this  action  from  without 
is  exerted  more  gradually,  so  that  absorption  is 
delayed.  Simple  suction  by  the  lymph-stream 
is  a  factor  which  may,  in  Schleich's  opinion,  be 
neglected. 

We  cannot  agree  with  this  explanation  of 
Schleich's,  for  we  find  that  the  rule  holds  also 
for  injections  which  are  not  made  according  to 
Schleich's  method,  and  in  which  cedema  and 
ischsemia  of  the  tissues  cannot  play  any  part. 
Further,  it  holds  also  in  the  case  of  applications 
to  a  mucous  membrane,  where  it  is,  of  course, 
beyond  question  that  no  pressure  is  exerted  on 
the  cocain  solution.  The  following  seems  to  us  a 
far  simpler  explanation  : 

Let  us  assume  that  we  have  in  a  cubic  centi- 
metre of  a  1  per  cent,  solution  100  molecules  of 
cocain,  then  in  a  cubic  centimetre  of  a  10  per  cent, 
solution  we  shall  have  1,000  molecules.  Now,  if 
we  inject  these  two  cubic  centimetres  under  the 
skin  of  two  separate  individuals,  a  fluid  deposit 
of  the  same  size  will  be  formed  in  each  case.      In 


24  LOCAL  ANAESTHESIA 

the  first  case  the  100  molecules  will  readily  find 
100  molecules  of  protoplasm  with  which  to  combine, 
thus  remaining  anchored,  so  to  speak,  at  the  site  of 
injection.  The  1,000  molecules,  however,  will  not 
find  molecules  of  protoplasm  to  combine  with  and 
fix  them  all,  and  the  surplus,  say  500,  will  pass 
quickly  into  the  blood-stream,  and  so  reach  the 
central  nervous  system  and  give  rise  to  symptoms 
of  acute  poisoning. 

Such  being  the  conditions  which  determine  the 
the  supervention  of  cocain-poisoning,  it  is  possible 
to  infer  from  them  what  objects  we  have  to  aim  at 
in  order  to  obviate  the  dangler — 

1.  We  must  endeavour  to  delay  the  absorption 
of  cocain  into  the  bloodstream. 

2.  We  must  use  solutions  as  dilute  as  possible. 
The  first  point  will  be  dealt  with  in    the  next 

chapter  ;  as  regards  the  second  it  has  been  found 
that  a  1  per  cent,  solution  is  the  strongest  that 
should  be  injected  subcutaneously,  and  this  only 
when  special  means,  which  w^e  shall  discuss  later, 
are  adopted  with  a  view  to  delaying  absorption ; 
and  I  cannot  help  suspecting  that  Reclus,  who 
states  that  he  has  performed  several  thousand 
operations  with  use  of  1  per  cent,  solutions,  without 
a  death,  must  have  used  preparations  of  cocain 
weaker  than  those  at  present  at  our  disposal,  or 
that  his  sterilizing  precautions  must  in  some  way 
have    weakened    the    action    of    his    injections. 


LOCAL  ANESTHETICS  25 

According  to  Brauii,  the  largest  quantity  of  a 
1*0  per  cent,  solution,  with  suprarenin,  which  can  be 
regarded  as  safe  is  5  c.c,  whereas  of  a  O'l  per  cent, 
solution  100  c.c,  or  double  the  maximal  dose  of 
cocain  in  the  more  concentrated  solution,  can  be 
injected  without  risk. 

Dosage  becomes  a  matter  of  great  difficulty  in 
apj)lications  to  the  oral  and  nasal  mucous  mem- 
branes. Here,  in  order  to  get  anaesthesia,  one 
must  paint  with  10  to  20  per  cent,  solutions. 
In  this  method  it  is  quite  impossible  to  say 
how  much  is  absorbed.  It  is  important  that  the 
solution  should  be  applied,  not  to  a  large  area 
of  mucous  membrane  at  once,  but  to  small  areas, 
if  necessary,  in  succession.  With  all  precautions, 
however,  as  I  have  learnt  from  repeated  experi- 
ences, it  is  impossible  to  avoid  cocain-poisoning 
altogether  and  with  certainty  in  this  method, 
though  I  have  not  seen  any  really  severe  cases. 
The  best  precautionary  measure  would  be  to 
avoid  cocain  altogether,  and  use  only  its  sub- 
stitute preparations  {ctlypin,  novocain)  ;  it  must 
be  admitted,  however,  that  a  considerable 
number  of  authors  consider  cocain  to  be  superior 
to  its  substitutes  as  an  anaesthetic  for  mucous 
membrane. 

In  the  case  of  hollow  organs  (such  as  the 
bladder  or  the  interior  of  a  joint),  where  we  can 
give    the    drug    sufficient   time    to    produce    its 


26  LOCAL  ANESTHESIA 

effect,  satisfactory  results  are  obtained  with  quite 
dilute  solutions  (0*1  and  0*2  per  cent.). 

It  ought  not  to  be  necessary  to  insist  that 
cocain  should  not  be  injected  into  young  children. 
Nevertheless,  even  infants  in  arms  have  been 
successfully  cocainized. 

Special  care  is  necessary  with  cocain  in  the  case 
of  anaemic  and  cachectic  patients,  as  such  patients 
often  exhibit  marked  intolerance  of  the  drug. 

In  the  treatment  of  acute  cocain-poisoning  the 
first  indication  is  to  place  the  patient  in  a  hori- 
zontal position,  w^ith  the  head  somewhat  lowered. 
The  face  should  be  sprinkled  with  cold  water,  and 
all  windows  should  be  opened.  If  amyl-nitrite  is 
at  hand,  a  few  drops  should  be  admiaistered  by 
inhalation.  Though,  according  to  Dastra,  it  is 
not  theoretically  an  antagonist  to  cocain,  it,  never- 
theless, often  acts  exceedingly  well  in  practice. 
In  women  all  constricting  garments  should,  of 
course,  be  loosened. 

In  severe  cases  caffeine  or  camphor  should  be 
given  hypodermically,  the  body  should  be  vigor- 
ously rubbed  or  flicked  with  wet  towels ;  should 
the  breathing  begin  to  fail,  artificial  respiration 
must  be  resorted  to. 

The  sterilization  of  cocain  must  be  carried  out 
with  great  care,  as  the  drug  is  readily  decomposed 
by  heat,  with  loss  of  anaesthetic  power.  Above  all 
things,  it  is  important  that  the  solutions  employed 


LOCAL  ANESTHETICS  27 

should  be  made  immediately  before  use.  The 
simplest  method  of  sterilization  is  to  raise  the 
solution  once  to  the  boiling-point.  Cocain  will 
bear  this  without  undergoing  decomposition.  Pro- 
longed boiling  causes  decomposition  of  the  active 
substance.  According  to  Braun,  cocain  in  powder 
or  tablet  form  may  be  heated  to  80°  C.  for  an 
hour  on  each  of  three  successive  days,  and  then 
dissolved  in  sterile  salt  solution. 

Chemists  have  for  a  long  time  endeavoured  to 
provide  substitutes  for  cocain.  which,  while  little, 
if  at  all,  less  powerful  as  anaesthetics,  shall  be 
without  its  toxic  properties.  Of  the  substances 
with  which  chemical  industry  has  furnished  us  up 
to  now  some  are  chemically  closely  allied  to 
cocain  {trojjacocain,  eucain,  novocain),  while  a 
series  of  others  belong  to  the  orthoform  group 
(orthoform,  nirvanin).  Only  a  few  of  these  bodies 
have  established  themselves  in  practice.  We  will 
deal  here  with  the  more  important  of  them. 

Tropacocain  is  much,  used  in  spinal  anaesthesia, 
of  which  we  shall  not  treat  here,  as  it  is  not, 
strictly  speaking,  a  form  of  local  ansesthesia.  It 
has  also  proved  useful  in  2  to  3  per  cent,  solutions 
in  ophthalmology.  When  injected  subcutaneously, 
however,  it  is  of  use  only  for  operations  of  very 
short  duration,  as  its  anaesthetic  eflPect  quickly 
passes  ofP.  It  does  not,  like  cocain,  cause  anaemia, 
nor    has    it    been   found   to   cause   injury   to   the 


28  LOCAL  ANESTHESIA 

tissues.  According  to  Braun,  up  to  0'2  gramme 
of  the  substance  may  be  given  in  1  per  cent,  solu- 
tion. No  by-effects  have  been  observed  from 
injections  of  solutions  of  that  strength.  Steriliza- 
tion is  most  conveniently  carried  out  by  boiling 
the  solution  for  five  minutes.  Addition  of  supra- 
renal preparations  does  not  increase  the  effect  of 
tropacocain. 

Eucain  /3,  which  was  at  one  time  widely  used, 
has  now  almost  disappeared  from  practice.  Its 
property  of  causing  hypersemia  and  the  impossi- 
bility of  combining  it  with  suprarenal  prepara- 
tions, have  stood  in  the  way  of  its  extended  use. 
Its  use  is  now  practically  confined  to  ophthal- 
mologists, many  of  whom  still  recommend  it  for 
subconjunctival  injections.  To  the  two  hitherto 
recorded  cases  of  poisoning  I  am  able  to  add  a 
third.  A  solution  of  1  in  30  was  injected  into  the 
slightly  ulcerated  bladder  of  an  elderly  man.  The 
most  severe  collapse  followed  immediately,  com- 
plete pulselessness  and  cessation  of  respiration. 
The  condition  seemed  desperate,  but  artificial 
respiration,  with  injections  of  camphor  and 
caffein,  brought  the  patient  round  in  about  ten 
minutes. 

Alypin,  a  glycerin  derivative  [mono chlorhydr ate 
of  benzoyl),  is  now  used  by  many  ophthalmologists 
in  place  of  cocain.  The  drug  acts  on  the  eye  in 
about  the  same  strength  of  dose  as  cocain,  but  is 


LOCAL  ANAESTHETICS  29 

less  poisonous.  The  lethal  close  is  about  double 
that  of  cocain.  Alypin  differs  from  cocain  in 
caushig  dilatation  instead  of  constriction  of  blood- 
vessels. It  does  not,  like  cocain,  cause  mydriasis 
nor  paralysis  of  accommodation.  It  may  be  com- 
bined with  suprarenal  preparations.  It  is,  further, 
less  harmful  to  the  cornea  than  cocain.  It  may  be 
sterilized  by  boiling  for  five  to  ten  minutes.  Solu- 
tions of  2  per  cent,  strength  are  generally  used 
for  conjunctival  instillation.  In  rhino-laryngology, 
also,  the  drug  has  many  advocates.  It  is  here 
painted  on  the  mucous  membrane  in  10  to  25  per 
cent,  solution. 

Alypin  shares  with  novocain  the  preference  of 
a  good  many  surgeons.  Apart  from  Schleich,  who 
uses  it  as  a  substitute  for  dilute  solutions  of  cocain, 
Schloffer,  for  instance,  has  carried  out  with  it  a 
series  of  strumectomies.  For  infiltration  0*5  to 
2  per  cent,  solutions  are  employed.  So  far  as  I 
am  acquainted  with  the  literature  of  the  subject, 
no  mishaps  have  been  reported  from  its  use. 

Stovain,  on  account  of  its  irritating  properties, 
is  not  suitable  as  a  local  aneesthetic. 

A  substance  which  has  rapidly  won  for  itself,  in 
the  estimation  of  general  surgeons  at  any  rate, 
the  first  place  as  a  local  ansesthetic  is  novocain 
{Maister,  Lucius,  and  Braning),  which  during  the 
last  few  years  has  assumed  a  position  of  com- 
manding importance  in  surgery,  so  that,  in  most 


30  LOCAL  ANESTHESIA 

of  the  great  surgical  cliniques,  it  is  now  exclu- 
sively employed  for  anaesthetic  injections. 

Novocain  [monochlorhydrate  of  para-amido- 
henzoyldiethylaTiiidoethanoT)  is  a  white,  crystalline 
powder,  which  can  be  heated  to  120°  C.  without 
decomposing,  and  is  readily  soluble  in  water  and 
alcohol. 

Pharmacological  tests  and  clinical  experience 
alike  have  shown  that  the  drug  does  not  act  as 
an  irritant  even  in  concentrated  solutions.  Its 
toxicity  is  only  about  one-seventh  of  that  of  cocain. 
So  far  as  I  am  aware,  no  case  of  novocain-poison- 
ing  has  yet  been  recorded  in  practice.  Occasion- 
ally injections  of  large  doses  have  been  followed 
by  slight  faintness  and  pallor ;  these,  however, 
have  been  quite  transient.  Half  a  gramme 
(7 '7  grains)  of  the  drug  may  be  injected  in  1  per 
cent,  solution  without  risk.  I  have  injected  as 
much  as  80  c.c.  of  such  a  solution — i.e.,  0"8  gramme, 
or  12 '3  grains,  of  the  drug,  without  any  untoward 
symptom. 

It  has  been  stated  that  novocain  is  quite  as 
powerful  an  anaesthetic  as  cocain.  This  is,  how- 
ever, not  quite  correct.  In  Oberst's  method  we 
have  found  that  its  action  is  weaker,  the  anaes- 
thetic efficiency  of  its  solutions  being  about  as 
1  :  2  when  compared  with  solutions  of  cocain  of 
equal  strength.  The  non-poisonous  character  of 
the    drug,    however,    admits    of    our    employing 


LOCAL  ANESTHETICS  31 

double  the  maximum  dose  of  cocain.  Solutions 
of  novocain  may  be  boiled  for  ten  minutes  with- 
out losing  strength. 

Novocain  does  not,  like  cocain,  cause  local 
anaemia  ;  where  this  effect  is  desired,  therefore, 
suprarenal  preparations  must  be  added  to  the 
solutions.  While  eucain  /3  loses  in  anaesthetic 
power  through  the  addition  of  adrenalin,  novocain, 
on  the  contrary,  has  its  efficiency  heightened. 
Novocain  is  also  very  suitable  in  10  to  20  per 
cent,  solutions  as  an  anaesthetic  for  mucous 
membrane.  It  has  here,  however,  to  compete 
with  alypin,  which  is  also  widely  used,  while 
cocain  also  has,  in  this  connection,  many  advo- 
cates. An  advantage  attributed  by  many  writers 
to  novocain  is  that  there  is  much  less  pain  after 
its  employment  than  is  the  case  with  cocain.  I 
do  not  think,  however,  that  there  is,  in  this 
respect,  any  very  great  difference  between  the 
two  drugs,  the  intensity  of  the  after-pain  depend- 
ing much  more  on  the  quantity  and  concentra- 
tion of  the  added  suprarenal  preparation. 

When  the  various  factors  are  taken  into  con- 
sideration, there  is  no  doubt  that  the  introduction 
of  novocain  represents  a  notable  advance,  as, 
indeed,  the  very  rapid  extension  of  its  employ- 
ment sufficiently  proves. 

Finally,  mention  must  be  made  of  the  anaes- 
thetics which   act  by  production  of  cold.     These 


32 


LOCAL  ANESTHESIA 


played  formerly  quite  an  important  part.  They 
have  now,  however,  been  relegated  to  a  very 
subordinate  position,  and  are  employed  only  for 
trifling  operations.  Ansesthesia  from  cold  is  a 
terminal  ansesthesia,  the  organs  acted  upon  being 
the  sensory  nerve-endings. 

Sulphuric  ether,  which  was  at  one  time  very 
widely  used,  has  now  been  almost  entirely  dis- 
placed by  more  powerfully  acting 
substances.  It  was  sprayed  on 
to  the  skin  or  mucous  mem- 
brane by  means  of  Richard- 
son's ether  spray  (Fig.  1).  The 
apparatus  consists  of  a  bottle 
filled  with  ether  and  fitted 
with  a  perforated  cork,  through 
w^hich  passes  a  tube,  one  eod  of 
which  is  covered  by  the  ether 
in  the  bottle,  while  the  other  is 
drawn  out  to  a  fine  point.  By 
means  of  the  well-known  rubber  bulb  arrangement 
air  is  forced  into  the  bottle,  the  increase  of  pressure 
forcing  the  ether  along  the  tube  until  it  emerges 
at  the  fine  exit  from  the  nozzle  in  a  jet  of 
minutely-divided  spray,  which  is  directed  on  to 
the  skin  or  mucous  membrane.  The  degree  of 
cold  produced  by  evaporation  of  the  ether  reaches 
about  -  15°  C.  The  ether — anaesthetic  ether  free 
from  water  must  be  used — is  sprayed  on  to  the 


Fig.  1. 


LOCAL  ANESTHETICS  33 

skin  from  a  short  distance.  After  a  few  minutes 
the  skin  becomes  white  and  frozen.  Until  this 
change  occurs  the  anaesthesia  is  not  complete.  If 
the  blanching  is  delayed,  a  slight  mechanical 
irritation  such  as  a  prick  with  the  point  of  a 
knife  is  often  sufficient  to  bring  the  skin  or 
mucous  membrane  quickly  into  a  frozen  condi- 
tion. The  ether  spray  is  useless  in  a  very  warm 
room,  as  under  such  condition  the  necessary 
degree  of  cold  cannot  be  attained.  The  more 
vascular  the  tissue,  the  more  difficult  it  is  to 
bring  it  to  the  freezing-point.  Formerly  the 
extremities  were  frequently  rendered  bloodless 
by  the  ordinary  surgical  methods  before  applying 
the  spray.  Before  the  onset  of  the  anaesthesia 
pain  is  often  felt,  slight  if  the  skin  be  healthy, 
but  often  severe  if  it  be  inflamed.  The  thawing 
of  the  frozen  parts  is  always  accompanied  by  a 
condition  of  hypersesthesia. 

The  drawbacks  associated  with  ether,  the  slow 
irregular  onset  of  the  anaesthesia  and  its  slight 
intensity,  have  led  to  the  adoption  of  other 
substances  with  a  lower  boiling-point,  whose 
spray,  therefore,  produces  a  greater  degree  of  cold 
by  evaporation.  The  most  useful  of  these  sub- 
stances is  ethyl  chloride  or  chlorethyl,  CJlfil. 
This  compound  boils  at  11°  C,  thus  at  about  the 
ordinary  room  temperature.  It  is  supplied  in 
glass    tubes    containing   15,    30,    50,   or    100  c.c. 

3 


34  LOCAL  ANESTHESIA 

The  tubes  are  generally  fitted  with  an  automatic 
tap  {h,  Fig.  2),  which  enables  one  to  close  or 
open  at  will  a  fine  opening  at  one  end  of  the 
tube,  so  that  by  holding  the  opening  downwards 
a  fine  jet  of  the  fiuid  can  be  obtained.  It  is  very 
necessary — and  this  point  is  often  neglected— to 
remove  fats  from  the  skin  by  benzine  or  ether 
before  applying  the  chlorethyl ;  otherwise  one  must 


Fig.  2. 

often  wait  a  long  time  for  the  onset  of  anaes- 
thesia. The  tube  must  not  be  held  too  near  the 
part  to  be  treated,  but  must  deliver  its  jet  from  a 
distance  of  about  30  centimetres  (1  foot),  so  that 
evaporation  may  have  already  begun  when  it 
reaches  the  skin  or  mucous  membrane.  The  buccal 
mucous  membrane  is  often  difficult  to  freeze  on 
account  of  the  passage  over  it   of  the    warmed 


LOCAL  ANAESTHETICS  35 

breath.  For  tooth  extraction  Kuehnen  has  intro- 
duced a  special  bifurcated  attachment  by  which 
both  aspects  of  the  gum  may  be  simultaneously 
sprayed  in  a  manner  similar  to  that  in  use  with 
ether.  The  tissues  must,  of  course,  only  be 
sprayed  until  blanching  appears  ;  otherwise  per- 
manent injury  may  be  done. 

It  has  been  stated  that  with  ethyl  chloride  it 
is  not  safe  to  render  the  part  bloodless,  as  is 
frequently  done  with  ether,  as  the  effect  pro- 
duced is  likely  to  be  too  powerful.  I  hardly 
think  there  is  any  real  danger  of  the  kind,  but 
as  the  application  of  a  tourniquet  is  uncomfort- 
able and  has  little  effect  in  intensifying  the 
anaesthesia,  there  seems  no  advantaofe  in  its  use. 

The  pain  which  often  comes  on  before  the 
onset  of  ansesthesia  is  more  severe  than  with 
ether,  in  consequence  of  the  more  rapid  freezing. 
It  is  especially  marked  if  the  tissues  be  inflamed. 

With  ether,  again,  a  deeper  effect  can  be 
produced  than  with  ethyl  chloride.  Neverthe- 
less, I  cannot  advocate,  with  Braun,  a  return  to 
a  more  extended  u.se  of  the  ether  spray,  and  I 
think  few  who  have  had  much  experience  of  the 
annoyance  and  loss  of  time  inseparable  from  the 
method  will  prefer  it  to  the  more  convenient 
ethyl  chloride,  in  spite  of  the  fact  that  the  latter 
possesses  also  some  disadvantages. 

Of  substances  possessing  a  still  lower  boiling- 


36  LOCAL  ANESTHESIA 

point  than  ethyl  chloride  I  have  practical  experi- 
ence only  of  ansestol  [Speyer  and  Karger).  This 
is  a  mixture  of  chlorethyl  and  chlormethyl,  the 
latter  of  which  boils  at  -23°  C.  It  acts  rather 
more  rapidly  than  chlorethyl.  I  have  seen  no 
injury  to  tissue  from  its  use,  though  I  have 
applied  it  for  some  minutes  in  attempts  to 
remove  an  angioma. 

For  the  production  of  still  more  intense  effects 
of  cold,  such  as  can  be  produced  by  the  use 
of  methyl  chloride,  or  of  liquefied  or  solidified 
carbonic  acid,  there  is,  for  purposes  of  ^  local 
anaesthesia,  no  necessity.  The  danger  of  injury 
to  the  tissues,  too— gangrene  of  the  skin  has  been 
observed  after  the  use  of  methyl  chloride— must 
be  held  to  contra-indicate  the  use  of  these  sub- 
stances in  practice. 


CHAPTER  IV 

ADJUVANTS  IN  LOCAL  ANAESTHESIA 

These  all  have  one  thing  in  common  :  they  act 
upon  the  circulation  in  such  a  manner  that  the 
blood-stream  is  slowed  at  the  point  where  the 
local  anaesthetic  is  required  to  produce  its  effect. 
By  this  slowing  of  the  blood,  and  consequentially 
of  the  lymph -stream,  the  absorption  of  the  an- 
aesthetic is  delayed,  and  the  danger  of  general 
poisoning  therewith  lessened.  Another  conse- 
quence of  this  delaying  of  absorption  is  that  the 
anaesthetic  is  allowed  to  remain  longer  about  the 
site  of  injection,  where  it  may  form  combinations 
with  the  protoplasm  of  the  tissues,  and  thus 
develop  to  the  full  its  anaesthetic  effect.  This 
effect  of  a  slowing  of  the  blood-stream  may  be 
demonstrated  experimentally  as  follows  :  a  certain 
quantity  of  an  aqueous  solution  of  eosin  is 
injected  endermically  into  one  arm  and  a  similar 
quantity  into  the  other  after  application  of  a 
tourniquet.  It  is  then  seen  that  on  the  ligatured 
side  a  very  much  larger  quantity  of  the  colouring 
matter   remains   and  becomes  diffused  about  the 

37 


38  LOCAL  ANESTHESIA 

site  of  injection  than  is  the  case  on  the  unhgatured, 
on  which  a  far  larger  quantity  of  the  eosin  has 
obviously  been  taken  up  into  the  general  blood- 
stream (^Braun). 

This  delay  of  absorption,  with  its  converse 
intensification  of  local  action,  involves  in  its  turn 
a  certain  danger.  By  the  slowing  of  the  blood- 
stream at  the  site  of  injection  the  vitality  of  the 
tissues  is  diminished,  and  too  prolonged  and  too 
intense  action  of  the  anaesthetic  on  the  proto- 
plasm within  its  reach  may  lead  to  injury  to  the 
tissues ;  one  must  aim,  therefore,  at  such  a 
balancing  of  effects  that  the  anaesthesia  may  be 
as  complete  as  possible  without  involving  any 
harmful  toxic  action  on  the  tissues. 


1.  Cold. 

Cold  has  not  won  a  position  of  any  great 
importance  as  an  adjuvant  in  the  production  of 
local  anaesthesia.  Brief  mention,  however,  may 
be  made  of  methods  of  application  which  have 
had  a  certain  vogue. 

{a)  Tubes  of  cocain-chlorethyl  are  now  sold 
containing  solutions  of  cocaln  in  ethyl  chloride  of 
different  concentrations  (1  to  5  per  cent.).  When 
this  preparation  is  applied  to  mucous  membrane, 
sensibility  is  abolished  temporarily,  and  returns 
only  with  the  thawing  of  the  frozen  parts.     Then, 


ADJUVANTS  IN  LOCAL  ANESTHESIA         39 

after  a  time,  there  supervenes  an  intense  cocain 
anaesthesia,  which  is  of  considerable  duration.  The 
same  result  may  be  brought  about  by  painting 
the  surface  with  cocain  solution  and  then  applying 
the  ethyl  chloride  jet.  The  nature  of  the  action 
is  as  above  explained.  Absorption  is  slowed,  or 
even  abolished,  in  the  cooled  parts,  and  the  local 
action  of  the  cocain  thereby  intensified,  and  the 
risk  of  general  poisoning  diminished. 

The  introduction  of  the  suprarenal  prepara- 
tions, to  be  dealt  with  later,  has  rendered  this 
method  of  applying  anaesthetics  more  and  more 
superfluous.  In  tooth  extraction,  for  which  the 
method  was  especially  advocated,  it  enables  us  to 
anaesthetize  merely  the  mucous  membrane,  not 
the  sensory  nerves  supplying  the  tooth. 

(b)  Schleich  has  recommended  the  injection  of 
powerfully  cooled  solutions,  again  with  a  view  to 
the  slowing  of  absorption  and  the  intensification 
of  local  action.  Others  {Braun),  when,  for  some 
reason,  they  do  not  wish  to  make  use  of  supra- 
renal preparations,  frequently  apply  the  ether 
spray  in  order  to  heighten  the  local  effect  of  an 
ansesthetic  injection.  I  have  never  found  any 
such  proceeding  necessary.  Schleich,  too,  seems 
but  seldom  to  have  recourse  to  it. 


40  LOCAL  ANAESTHESIA 

2.  Methods  for  rendering  the  Parts 
Bloodless. 

(a)  Ligature. 

This  method,  to  whose  importance  attention 
was  first  drawn  by  Corning,  also  acts  by  stoppage 
of  the  circulation  and  consequent  inhibition  of 
absorption  and  intensification  of  local  anaesthetic 
action.  Klapp  has  proved  this  experimentally. 
He  injected  solutions  of  milk-sugar  under  the 
skin  of  the  arm.  The  sugar  was  rapidly  absorbed 
and  excreted  in  the  urine.  The  application  of  a 
tourniquet  caused  a  marked  slowing  of  absorption. 
It  was  formerly  thought  that  rendering  a  part 
bloodless  had  in  itself  an  anaesthetic  effect.  Braun 
has  shown,  however,  that  anaesthesia  follows  the 
application  of  a  constricting  band  only  if  the  band 
is  applied  very  tightly  so  that  the  nerve-trunks 
are  compressed.  The  anaesthesia  brought  about 
in  this  manner  depends,  therefore,  directly  on  the 
tightness  of  the  constriction  and  the  position  of 
the  nerve-trunks  at  the  point  where  the  constrict- 
ing band  is  applied.  It  is  quite  uncertain,  and 
therefore  of  no  practical  significance. 

In  operations  on  the  fingers  and  toes  the 
emptying  of  the  parts  of  blood  has  been  widely 
adopted  as  an  auxiliary  to  the  so-called  Oherst's 
Anoesthesia.     At  the  present  time,  however,   the 


ADJUVANTS  IN  LOCAL  ANESTHESIA         41 

use  of  suprarenal  preparations  is  generally  pre- 
ferred. Bloodless  methods  cannot,  however,  be 
dispensed  with  altogether.  If  the  bandage  is 
carefully  and  not  too  tightly  applied  to  the  fore- 
arm— a  tight  constriction  is  not  at  all  necessary 
— the  method  has  few,  if  any,  drawbacks.  It  is 
specially  applicable  when  the  site  of  operation  is 
at  the  base  of  the  finger,  or  at  a  still  more  central 
point,  where  -an  anaesthetic  condition  is  not  so 
easily  attained  as  in  the  finger  itself,  and  when 
we  wish  to  avoid  using  the  larger  dose  of  supra- 
renal extract  which  is  here  generally  necessary. 

The  use  of  constriction  to  render  the  afiected 
parts  bloodless  is  again  playing  an  important  part 
since  the  introduction  of  Bier's  method  of  venous 
ancesthesia.  As  we  have  stated,  in  this  method  a 
section  of  the  limb  having  been  rendered  bloodless 
and  included  between  two  constricting  bandages, 
a  i  per  cent,  novocain  solution  is  injected  into  one 
of  its  veins.  Bier  has  shown  that  fluids  pass 
through  the  venous  wall  with  extraordinary 
facility.  The  solution,  therefore,  injected  under 
pressure  into  the  vein  rapidly  permeates  all  the 
tissues  within  its  reach. 

{b)  Infiltration  (Schleich). 

In  Schleich 's  view  chemical  factors  play  only  a 
secondary  part  in  his  method  of  "  oedematizing  " 
the  site  of  operation.     Their  function  is  to  counter- 


42  LOCAL  ANESTHESIA 

act  the  pain  due  to  the  injection ;  the  chief  part 
is  played  by  the  2  per  cent,  salt  solution,  and 
anaemia  and  pressure  act  as  auxiliaries. 

The  action  of  the  2  per  cent,  salt  solution  will 
be  considered  in  the  next  chapter.  Ansemia  plays 
a  certain  part  if  the  method  is  correctly  carried 
out — that  is  to  say,  with  production  of  a  marked 
degree  of  (Bdema.  It  acts  in  the  manner  described 
at  the  commencement  of  this  chapter,  enabling  us 
to  make  use  of  dilute  solutions  and  heightening 
the  local  effect  of  the  anaesthetic  by  causing  a 
slowing  of  absorption. 

(c)  Suprarenal  Preparations. 

These  have  of  late  years  gained  a  position  of 
steadily-increasing  importance  in  the  practice  of 
local  ansesthesia.  After  attention  had  been  drawn 
by  Pellacini  to  certain  pharmacological  properties 
of  suprarenal  extract,  a  series  of  investigators 
[Tilrk,  Abel,  Takanwie,  Aldrich,  Oliver,  Schdfer) 
w^orked  at  the  isolation  of  its  active  principle  with 
ultimate  success.  A  number  of  different  prepara- 
tions were  now  put  on  the  market  in  corre- 
spondence with  the  different  methods  of  manu- 
facture employed ;  suprarenin  (Hochst),  epirenan 
{Byk),  paranephrin  [Merck),  adrenalin  {Parke, 
Davis)  and  others.  These  have  all  approximately 
the  same  constitution.  Following  the  suggestion 
of  Braun,  to  whom  we  owe  the  introduction  of  the 


ADJUVANTS  IN  LOCAL  ANAESTHESIA         43 

suprarenal  preparations  into  the  practice  of  local 
ansesthesia,  we  shall  hereafter  include  them  under 
the  general  name  suprarenin. 

Suprarenin  is  a  white  powder  which  dissolves 
freely  in  water,  but  combines  with  the  oxygen  of 
the  air  as  it  does  so,  and  takes  on  a  reddish  or 
brownish  tint.  On  the  other  hand,  it  dissolves 
freely  also  in  dilute  hydrochloric  acid  without 
undergoing  any  change.  It  is  therefore  generally 
sold  in  the  form  of  a  solution  of  suprarenin  hydro- 
chloride (1  in  1,000).  In  speaking  in  the  ensuing 
pages  of  suprarenin  solution  generally,  we  must 
be  understood,  unless  otherwise  stated,  to  refer  to 
the  1  in  1,000  solution.  Solutions  in  boric  acid 
are  less  frequently  used.  Hochst's  preparation 
contains  an  added  6  per  cent,  of  thymol.  The 
solutions  are  readily  decomposed  by  heat.  On 
standing,  also,  they  soon  undergo  change  and  take 
on  a  reddish  tint.  Solutions  in  this  condition 
should  on  no  account  be  used.  Apart  from  the 
fact  that  solutions  which  are  no  longer  clear  show 
a  diminished  efficiency  as  anaesthetics,  poisonous 
substances  are  formed  in  solutions  which  have 
been  kept  for  any  length  of  time,  and  these  may 
give  rise  to  unpleasant  symptoms  {vomiting, 
after-pain,  etc.).  One  fatal  case,  even,  has  been 
recorded.  A  positive  result  of  the  ferric  chloride 
reaction — an  emerald- green  coloration  on  adding 
ferric    chloride    to    an    acid    solution  ;    changing 


44  LOCAL  ANESTHESIA 

to  red  on  addition  of  ammonia — is  not  at  all 
reliable.  The  rubber  corks  with  which  the 
bottles  are  fitted  in  which  suprarenal  preparations 
are  generally  sent  out  are  very  inimical  to  the 
keeping  powers  of  the  solutions.  If  after  opening 
the  bottle — only  bottles  containing  a  very  small 
quantity  of  the  solution  should  be  employed — a 
cork  be  substituted  for  the  rubber  stopper,  the 
solution  will  remain  in  good  condition  for  a  very 
much  longer  period. 

The  instability  of  suprarenal  preparations,  the 
impossibility  of  sterilizing  them  with  certainty, 
and,  not  least,  their  inconstant  action,  have  led  to 
attempts  to  prepare  them  by  synthesis.  In  this  field 
Stolz,  the  chemist  to  the  Hochst  Works,  has  suc- 
ceeded in  synthesizing  several  substances  whose 
injection  calls  forth  the  same  effects — increase  of 
blood-pressure  and  peripheral  vaso-construction — 
as  does  that  of  suprarenin.  In  their  quantitative 
action,  however,  they  differ  among  themselves 
materially. 

Arterenin  (or  arterenol)  Braun  found  to  re- 
semble suprarenin  in  its  action.  Others,  how- 
ever, describe  it  as  quantitatively  inferior  to  that 
substance.     It  has  disappeared  from  practice. 

Homorenon  is  described  by  the  Hochst  firm  as 
being  fifty  times  less  poisonous  than  suprarenin. 
As,  however,  one  must  employ  5  per  cent,  solutions 
instead  of  those  of  1  in  1,000  strength,  the  gain  from 


ADJUVANTS  IN  LOCAL  ANAESTHESIA         45 

the  lower  degree  of  toxicity  is  very  problematical. 
Further,  accordiDg  to  Hoffmann,  the  activity  of 
the  preparation  is  lost  by  sterilization.  It,  like  the 
former  preparation,  has  failed  to  gain  a  place  in 
practice. 

The  preparation  which  has  won  the  largest 
degree  of  recognition  is  suprareninum  synthe- 
ticmn,  which  has  been  tested  by  various  observers, 
and  according  to  Braun  and  Hoffmann  is  a  little 
more  powerful  in  action  than  the  substance 
obtained  from  the  organ  itself.  It  is,  like  the  two 
foregoing  preparations,  a  white  crystalline  powder, 
which  is  unaltered  by  exposure  to  air,  dissolves  in 
water  acidulated  with  hydrochloric  acid,  and  gives 
the  ferric  chloride  reaction  described  above.  It 
must  be  kept  in  a  dark  place,  but  will  then  remain 
unchanged  for  a  considerable  time.  As  a  general 
rule  a  light  rose  colour  develops  in  the  solution, 
but  only  after  it  has  been  kept  for  some  time. 
The  solution  can  be  sterilized  by  a  brief  boiling 
immediately  before  use.  Repeated  sterilization  is 
not  advisable,  and,  if  only  small  bottles  are  used 
containing  small  quantities  of  the  solution,  hardly 
necessary.  If  making  one's  own  solution  of  com- 
mercial suprarenin  hydrochloride,  great  care  must 
be  taken  that  there  is  no  free  alkali  in  the  glass 
in  which  the  solution  is  boiled,  as  all  the  supra- 
renin preparations  are  very  sensitive  to  the  action 
of  free  alkali.     To  avoid  this  risk  it  is  a  good  plan 


46  LOCAL  ANESTHESIA 

to  use  the  small  bottles  supplied  by  the  manu- 
facturers. The  toxicity  of  synthetic  suprarenin 
is  somewhat  less  than  that  of  the  preparation 
made  from  the  gland  itself 

Judging  from  my  own  experience,  the  action  of 
synthetic  suprarenin  is  slightly  weaker  than  that 
of  its  predecessors.  The  dose  given  by  Hoffmann — 
viz.,  2  minims  to  10  c.c.  of  a  1  per  cent,  novocain 
solution — was  frequently  hardly  sufl&cient  to  cause 
any  marked  anaemia.  The  dose  I  have  generally 
employed  for  infiltration  anaesthesia  has  been  from 
2  to  4  minims  to  10  c.c.  of  the  solution.  That  the 
ideal  of  an  absolutely  pure  preparation  has  not 
been  reached  by  this  substance  we  may  gather 
from  the  introduction  by  the  Hochst  firm  of  a 
new  preparation,  Synthetic  L.  Suprarenin,  which 
turns  the  polarized  ray  to  the  left.  This  prepara- 
tion is  more  stable  and  more  constant  in  its  action 
than  the  first  synthetic  suprarenin,  which  has  now 
been  withdrawn  from  commerce.  Experience  w^ith 
this  new  suprarenin — clinical  experience  is  the  best 
criterion^ — is  not  at  present  extensive.  So  far  as  it 
goes,  the  preparation  would  seem  to  be  of  about 
equal  activity  with  the  earlier  synthetic  suprarenin. 

The  whole  suprarenin  question  is  not  yet  fully 
cleared  up.  Different  authors,  for  instance,  differ 
widely  from  each  other  on  the  question  of  dosage. 
Further  experience  is  required  to  decide  whether 
our  present  dosage  of  synthetic  suprarenin  is  not 


ADJUVANTS  IN  LOCAL  ANESTHESIA         47 

too  high,  and  also  whether  some  further  attempt 
ought  not  to  be  made  to  separate  the  toxic  from 
the  useful  elements.  The  maximal  dose  given  by 
Braun,  ^c.c.  =  8*5  minims  of  the  1  in  1,000  solution, 
is,  however,  a  very  small  one,  and  though  perhaps 
as  a  rule  sufficient,  some  slightly  greater  latitude 
as  to  dose  may,  I  think,  safely  be  allowed.  No 
fixed  scheme  of  dosage  can,  as  a  matter  of  fact,  be 
laid  down.  In  parts  well  supplied  with  blood 
more  suprarenin  must  be  used  than  in  parts  more 
poorly  supplied.  The  presence  of  a  considerable 
quantity  of  subcutaneous  fat  calls  frequently  for  a 
free  addition  of  sujDrarenin  as  an  adjuvant  to  the 
anaesthetic.  In  small  operations,  too,  in  which  not 
more  than  5  to  10  c.c.  of  the  anaesthetic  solution 
are  employed,  we  may  safely  add  1  or  2  drops 
more  of  the  solution  of  suprarenin  than  in  the 
case  of  larger  operations  w^here  the  dosage  of 
anaesthetic  already  approaches  the  maximum. 

In  general,  the  dosage  of  synthetic  suprarenin 
may  be  put  Sit  1  to  4:  drops  to  10  c.c.  of  ancesthetic 
solution  in  ''infiltration"  and  ''circular''  ancBS- 
thesia,  1  to  2  drops  per  c.c.  for  the  interruption  oj 
conduction  in  the  larger  nerve  trunks. 

To  pass  to  the  effects  of  suprarenin  preparations 
on  the  organism,  the  most  prominent  is  an  increase 
of  blood-pressure,  which  comes  on  even  after  a 
minimal  dose.  The  cause  of  this  increase  of  blood- 
pressure  is  a  direct  action  of  the  drug  on  the  heart- 


48  LOCAL  ANESTHESIA 

muscle  and  on  unstriped  muscle  throughout  the 
body,  especially  on  that  of  the  medium  sized  and 
smaller  bloodvessels. 

The  rules  governing  the  local  action  and  absorp- 
tion of  suprarenin  are  the  same  as  in  the  case 
of  cocain.  Suprarenin,  like  the  latter,  combines 
locally  with  the  tissue  protoplasm,  and  conse- 
quently, if  given  in  concentrated  solution,  yields 
up  its  surplus  to  the  blood-stream  more  readily 
than  if  more  dilute  solutions  are  employed. 

Suprarenal  preparations  injected  in  large  doses 
into  the  blood-stream  have  a  powerfully  poisonous 
action  on  the  organism.  While  small  injections 
cause  an  increase  of  blood-pressure  which  gradually 
passes  away,  with  larger  doses  there  follows,  after 
a  transient  rise,  a  fall  of  blood-pressure,  which  in 
severe  cases  may  lead  to  pulmonary  oedema,  con- 
vulsions, paralytic  phenomena,  and  death.  Braun 
has  studied  the  early  stages  of  suprarenin-poison- 
ing  on  himself  After  subcutaneous  injection  of 
rather  more  than  0*5  c.c.  of  1  in  1,000  solution 
he  was  seized  with  palpitation  and  a  feeling 
of  oppression ;  the  same  quantity  injected  in 
10  c.c.  of  salt  solution  caused  no  toxic  symptoms. 
Of  course,  in  intravenous  injection  a  very  much 
smaller  quantity  suffices  to  cause  symptoms  of 
general  poisoning  than  is  the  case  with  paren- 
chymatous injections.  The  prophylaxis  of  general 
suprarenin -poisoning  maybe  summed  up  as  follows : 


ADJUVANTS  IN  LOCAL  ANESTHESIA         49 

Give  small  doses  in  dilute  solution.  The  maximal 
dose  of  0*5  c.c.  given  by  Braun  is  quite  sufficient 
in  the  case  of  cocain  anaesthesia.  Even  as  an 
addition  to  novocain  solutions,  which,  in  my  ex- 
perience, require  somewhat  larger  additions  than 
cocain,  in  view  of  the  absence  of  any  ansemia- 
producing  action  in  novocain,  this  dose  will  gener- 
ally be  found  sufficient.  The  maximal  dose  of 
10  c.c.  of  1  in  1,000  solution,  given  by  Miiller, 
must  be  regarded  as,  in  the  majority  of  cases,  too 
large. 

The  way  in  which  suprarenin  acts  as  an  auxiliary 
in  local  ansesthesia  will  be  plain  from  what  we 
have  said  above.  The  contraction  of  the  arterial 
musculature  gives  rise  to  a  vaso-constriction  at 
the  seat  of  injection,  and  thus  produces  a  con- 
dition of  local  anaemia,  with  slowing  of  the  local 
circulation  and  consequent  delay  in  absorption, 
the  general  result  being  an  increase  of  local  anaes- 
thetic action  and  diminution  of  general  absorp- 
tion, with  its  attendant  risk  of  poisoning.  The 
duration  of  the  anaesthesia  is  also  increased  by 
the  addition  of  suprarenin. 

Suprarenal  preparations  have  in  themselves  no 
anaesthetic  action.  Concentrated  solutions  empty 
the  parts  so  completely  of  blood  that  not  a  drop 
issues  even  from  the  larger  vessels.  With  correct 
application  and  dosage  the  parts  become  prac- 
tically empty   of  blood  ;  from   the  larger  vessels 

4 


50  LOCAL  ANESTHESIA 

there  will  be  slight  oozing,  but  no  spurting  of 
blood.  This  action  of  suprarenin  is  of  assistance 
also  in  the  conduction- anaesthesia  which  will  be 
dealt  with  later  on,  for  though  here  the  supra- 
renin does  not,  as  a  rule,  act  directly  upon  the 
vessels  in  the  operation  area,  nevertheless,  the 
vessels  passing  to  that  area  contract  under  its 
influence  sufficiently  to  diminish  materially,  or 
even  to  inhibit,  the  blood-supply  to  the  part. 

We  have  seen  above  that  suprarenin  combines 
with  the  tissue  protoplasm.  The  combination  is  a 
somewhat  transitory  one ;  at  the  same  time,  it  is 
important  to  remember  that  when  we  use  a  mix- 
ture of  a  local  anaesthetic  with  suprarenin  we  are 
injecting  two  substances,  each  of  which  has  its 
own  local  poisonous  action.  The  greatest  caution 
is  therefore  called  for.  Injuries  to  tissue  through 
the  use  of  suprarenin  have  been  pretty  frequently 
observed,  and  several  cases  of  gangrene  have  been 
reported  in  patients,  the  subjects  of  arterial 
sclerosis  {Neugehauer).  I  myself,  when  the  use  of 
suprarenin  was  in  its  infancy,  have  seen  cutaneous 
gangrene  of  the  finger  develop  in  a  patient,  a 
professional  colleague.  It  would  seem,  however, 
that  with  our  present  dosage  we  are  fairly  safe 
from  such  mishaps. 

Schleich,  on  account  of  this  risk  of  injury  to 
tissues,  rejects  suprarenal  preparations  altogether. 
In  this  attitude,  however,  he  is  likely  to  stand 


ADJUVANTS  IN  LOCAL  ANESTHESIA  51 

alone.  Almost  every  method  has  its  dangers  and 
its  victims  at  first.  Only  gradually,  as  experience 
accumulates,  do  we  learn  to  avoid  the  dangers.  It 
is  worth  noting,  too,  that  in  Schleich's  method 
the  addition  of  suprarenin  may  probably  be  dis- 
pensed with,  as  the  oedema  it  produces  causes  a 
sufficient  degree  of  anaemia. 

The  second  danger  associated  with  suprarenin, 
that  of  secondary  haemorrhage,  can  now  be  avoided 
with  some  certainty.  Large  doses  of  suprarenin 
lead,  after  the  initial  vaso-constriction  has  passed 
off,  to  a  loss  of  vascular  tone  with  vaso-dilatation ; 
if  dilute  solutions  are  employed,  this  loss  of  tone 
does  not  occur,  or  occurs  only  in  so  slight  a  degree 
that  it  is  not  of  practical  significance. 

The  galvanic  current  as  an  auxiliary  in  local 
anaesthesia  is  at  present  merely  of  scientific,  not 
of  practical,  interest.  Wagner  and  Hertzog  apply 
to  the  skin,  which  is  generally  impermeable  to 
aqueous  solutions,  an  anode  soaked  in  cocain  solu- 
tion, and  by  this  means  bring  about  a  local  anaes- 
thesia. The  method,  however,  though  it  has  been 
given  some  trial  also  in  dentistry,  has  not  gained 
any  real  footing  in  practice. 


CHAPTER  y 

METHODS  OF  LOCAL  ANESTHESIA  AND  THEIR 
APPLICATION 

1.  Anesthesia  produced  by  Cold. 

This  method  is,  or  at  any  rate  should  be,  of  but 
occasional  application.  With  highly  sensitive 
patients  it  is  often  advisable  to  render  slight 
punctures  painless  by  means  of  the  ethyl  chloride 
jet.  This  is  especially  the  case  if  needles  of  large 
calibre  have  to  be  used,  as  in  saline  infusion. 
Broadly  speaking,  it  is  considerations  rather  of 
convenience  than  of  necessity  that  determine  the 
employment  of  the  method.  Small  boils,  quite 
superficial  whitlows,  visible  splinters,  etc.,  are 
suitable  for  operation  under  this  method.  It 
should,  however,  be  definitely  discarded  in  any 
case  of  more  extensive  inflammation.  Especially 
is  it  to  be  avoided  in  any  extensive  phlegmon  of 
the  fingers  or  hand.  In  the  out-patient  depart- 
ment of  any  large  hospital  it  is  a  very  common 
thing  to  see  cases  of  phlegmon  burrowing  deeply 
along  the  sheaths  of  the  tendons  or  elsewhere  in 
which,  a  day  or  two  before,  an  incision  has  been 

52 


METHODS  OF  LOCAL  ANESTHESIA  53 

made  under  ethyl  chloride  ansesthesia.  In  such 
cases  the  operator  cannot  possibly  have  deter- 
mined which  tissues  were  affected,  still  less  how 
far  the  suppurative  process  spread.  The  operation 
must  be  quickly  finished  on  account  of  the  tran- 
sitory nature  of  the  ansesthesia — if  any  sufficient 
degree  of  the  latter  be  attained  at  all — and  the 
part  bound  up  under  pressure — this  generally 
causing  severe  pain— on  account  of  the  free  bleed- 
ing which  supervenes  on  the  thawing  of  the  frozen 
parts.  It  is  the  same  with  large  boils  or  car- 
buncles. Here,  in  the  first  place,  if  the  inflam- 
mation is  severe,  the  application  of  the  jet  is  itself 
painful,  as  also  the  process  of  thawing ;  while,  in 
the  second  place,  the  incision  itself,  however 
quickly  made,  often  causes  very  severe  pain, 
because,  though  the  tissues  through  which  the 
actual  incision  is  made  are  insensitive,  it  is 
impossible  so  to  make  the  incision  as  to  avoid 
pressure  on  the  excessively  sensitive  nerves 
throughout  the  whole  inflamed  area.  I  have 
often  seen  surgeons  express  astonishment  at  a 
patient's  cry  of  pain,  because  they  knew  they  had 
cut  through  frozen  tissues  only;  and  I  have  even 
heard  them  ascribe  the  patient's  protest  to 
prejudice  against  local  ansesthesia. 

The  fact  that  major  operations— resection  of 
scapula,  ovariotomy,  etc. — have  been  carried  out 
under  ansesthesia  from  cold  is  of  merely  historical 


54  LOCAL  ANESTHESIA 

interest.  The  attempt  has  likewise  been  made  to 
render  large  nerve- trunks  insensitive  by  the 
application  of  cold.  The  pain,  however,  which 
here  precedes  the  onset  of  anaesthesia  is  so 
exceedingly  severe  as  to  surpass  in  most  cases  that 
of  the  operation  itself 

In  tooth  extraction  the  method  is  only  appro- 
priate when  the  tooth  is  quite  loose  and  free  from 
pulpitis,  so  that  all  that  is  required  is  to  render 
painless  prehension  of  the  tooth  by  the  forceps. 
A  small  operation  which  is  quite  satisfactorily 
carried  out  under  ethyl  chloride  anaesthesia  is 
removal  of  ingrowing  toe-nail  and  excision  of  the 
bed  of  the  nail.  It  is  essential,  however,  in  this 
operation  that  one  should,  before  operating,  see 
the  tissues  frozen  white  underneath  the  whole 
nail.  If  the  oj)eration  is  then  quickly  performed, 
it  can  be  completed  without  any  pain  at  all. 

2.  Anaesthesia  of  Mucous  and  Serous 
Surfaces. 

As  was  stated  in  the  first  chapter,  cocain  was 
first  applied  as  an  anaesthetic  to  the  conjunctiva. 
The  anaesthesia  is  here  a  terminal  one,  and  does 
not  generally  extend  beyond  the  mucosa.  Small 
doses  are  here  generally  sufiicient,  as  the  anaesthetic 
does  not  flow  away,  but  may  remain  in  the  con- 
junctival sac,  exerting  its  action  on  the  mucosa 
for  a  considerable  time. 


METHODS  OF  LOCAL  ANESTHESIA  55 

In  the  case  of  many  mucous  membranes  {e-ff;,, 
pharynx),  the  impossibility  of  accurate  dosage  has 
constituted  a  difficulty  of  some  moment.  As,  in 
consequence  of  the  limited  degree  to  which 
diffusion  can  take  place  through  the  uninjured 
mucous  membrane,  very  concentrated  solutions 
(10  per  cent,  to  20  per  cent,  cocain  solutions) 
have  to  be  used,  overdosage  is  difficult  to  avoid 
with  certainty,  and  cases  of  cocain-poisoning, 
fortunately,  as  a  rule,  slight,  have  been  fairly 
numerous.  In  these  cases  the  use  of  the  substi- 
tute preparations  is  especially  to  be  desired,  and 
in  many  surgical  cliniques  they  have  practically 
displaced  cocain.  The  use  of  suprarenal  prepara- 
tions admits,  further,  of  the  emj)loyment  of  more 
dilute  solutions  than  could  be  used  formerly.  The 
concentration  is,  of  course,  dependent  on  the  time 
that  can  be  allowed  to  the  solution  to  produce  its 
effect,  and  in  the  method  of  external  application  to 
a  mucous  membrane  by  swabbing  this  is,  of  course, 
especially  brief.  Thus,  for  anaesthetizing  the 
pharynx  the  solution  must  be  about  forty  times  as 
strong  as  for  the  bladder. 

An  anaesthetic  is  often  required  to  render  pain- 
less the  injection  of  an  irritant  solution  (iodine, 
phenol)  into  a  serous  cavity,  such  as  a  joint  or  a 
hydrocele  sac.  The  site  of  puncture  is  first 
''  infiltrated  "  with  0*5  per  cent,  novocain  solution, 
to   which    suprarenin   has    been    added,   and    the 


56  LOCAL  ANESTHESIA 

same  solution  is  then,  after  the  removal  of  the 
fluid  present,  injected  into  the  cavity  until  the 
latter  is  tightly  filled.  In  ten  minutes  complete 
anaesthesia  will  be  established,  and  not  only  may 
drugs  be  injected,  but  contractures  may  be  cor- 
rected so  long  as  they  are  merely  reflex,  and  not 
due  to  serious  structural  changes  in  the  joint. 

3.  Schleich's  Infiltration  Anesthesia. 

In  this  method  the  operation  area  is  infiltrated 
with  a  dilute  anaesthetic  solution  in  such  a  manner 
as  to  cause  a  marked  oedema  of  the  tissues,  so  that 
the  subcutaneous  cellular  tissue,  for  instance, 
appears  swollen  and  glassy.  The  skin  in  the 
neighbourhood  of  the  coming  incision  is  first 
infiltrated,  and  immediately  afterwards  the  sub- 
cutaneous cellular  tissue,  then,  gradually,  deeper 
and  deeper  layers  of  the  subjacent  tissues.  As 
the  discoverer  of  this  method,  Schleich  is  entitled 
to  the  credit  of  having  been  the  first  to  devise  a 
really  safe  method  of  local  anaesthesia,  as  it 
admits  of  the  use  of  very  dilute  solutions  of 
anaesthetic  drugs.  His  discovery  was  novel  in 
principle,  and  it  is  quite  incorrect  to  speak  of  a 
Reclus  -  Schleich  method  of  anaesthesia.  Reclus 
adopted  subsequently  much  of  Schleich's  tech- 
nique ;  he  worked,  however,  with  1  per  cent, 
solutions    of  cocain,    and    was   therefore   able   to 


METHODS  OF  LOCAL  ANESTHESIA  57 

Inject  only  very  small  quantities  of  the  solutions, 
forming  small  deposits,  so  to  speak,  of  concen- 
trated cocain  solution,  which  gradually  diffused 
themselves  into  the  surrounding  tissues,  and 
only  then  produced  any  widespread  effect. 
Schleich  first  anesthetized  the  skin  by  forming 
endermal  weals,  and  then  oedematized  the  subcu- 
taneous cellular  tissue.  Only  after  incision  of 
these  tissues,  now  insensitive,  were  the  deeper 
layers  infiltrated,  step  by  step,  with  large  quan- 
tities of  solution. 

At  first  Schleich  employed  three  solutions  of 
cocain,  a  0*2  per  cent.  (I.),  a  0*1  per  cent.  (II.),  and  a 
O'Ol  per  cent.  (III.).  In  each  the  cocain  was  dis- 
solved in  0*2  per  cent,  salt  solution;  a  small 
quantity  of  morphine  was  also  added.  Recently 
Schleich  has  substituted  alypin  for  a  |)ortion  of 
the  cocain — in  his  view  the  two  anaesthetics,  when 
mixed,  "  heighten  each  other's  potency  " — so  that 
the  solutions  he  employs  at  present  have  the 
following  formulae  : 

Solution  I.  Solution  II.  Solution  III, 

01  cocain.  0'0.5  cocain.  0*01  cocain. 

0*1  alypin.  0  0.5  alypin.  D'Ol  alypin. 

0*1  sodium  chloride.         0'2    sodium  chloride.       0*2    sodium  chloride. 

100-0  aq.  dest.  100-0    aq.  dest.  lOO'O    aq.  dest. 

It  would  seem  that  Schleich  no  longer  adds 
morphine  to  his  solutions  ;  we  need  not,  therefore, 
discuss  the  significance  of  such  addition 


58  LOCAL  ANESTHESIA 

Schleich  believes  that  in  the  0*2  per  cent,  solution 
of  common  salt  he  has  found  a  fluid  which,  pos- 
sessing a  concentration  intermediate  between 
that  of  physiological  salt  solution  and  pure  water, 
can,  like  the  former,  be  injected  without  causing 
pain,  and,  like  the  latter,  when  injected,  causes 
anaesthesia.  This  0*2  per  cent,  salt  solution  must 
then  be  regarded  as,  in  itself,  an  anaesthetic,  and 
this  is  the  essentially  novel  feature  in  his  method. 
A  second  factor  of  importance  in  the  method  is 
the  artificially-produced  oedema  and  consequent 
(1)  ischsemia  and  (2)  compression  of  sensory  nerve- 
endings.  Another  factor  working  in  the  same 
direction  is  the  diflerence  in  temperature  between 
the  blood  and  the  solution,  which  is  injected  at 
the  ordinary  room  temperature,  or  is  even  cooled 
before  injection  with  a  view  to  increasing  the 
difference.  The  method  is  therefore,  in  the 
main,  one  depending  on  physical  principles,  the 
cocain  itself  fulfilling,  in  Schleich 's  opinion,  quite 
a  secondary  role,  its  main  function  being  to  deaden 
the  pain  caused  by  the  actual  infiltration,  and 
especially  to  over-compensate  for  the  hyper- 
aesthetic  condition  of  inflamed  tissues.  If  the 
operative  procedures  are  carried  out  on  absolutely 
healthy  (uninflamed)  tissues,  they  may  be  carried 
out  quite  satisfactorily  with  0*2  per  cent,  salt 
solution  alone,  without  any  anaesthetic  drug. 

The  whole  theoretical  basis  of  Schleich 's  teach- 


METHODS  OF  LOCAL  ANESTHESIA  59 

ing  has  been  vigorously  attacked  by  Braun,  who 
challenges  esj)ecially  Schleich  s  views  as  to  the 
part  played  in  local  anaesthesia  by  the  0*2  per  cent, 
salt  solution.  We  have  seen  above  that  a  0*2  per 
cent,  solution  does  actually  cause  anaesthesia 
{Quellungsandsthesie)  when  injected.  This  anaes- 
thesia, however,  is  preceded  by  pain,  due  to  the 
injection  ;  and  though  this  pain  is  less  severe  than 
when  pure  water  is  injected,  so  also  is  the  intensity 
and  duration  of  the  anaesthesia  less  than  in  the 
case  of  water.  While,  then,  Braun  freely  admits 
that  a  slight,  transient  anaesthesia  may  be  pro- 
duced by  injection  of  a  0*2  per  cent,  salt  solution, 
he  maintains  that  the  effect  of  a  0*1  per  cent, 
solution  of  cocain,  such  as  is  contained  in  the 
most  frequently  used  No.  II.  solution  of 
Schleich,  so  enormously  surpasses  this  "  physical  " 
anaesthesia  as  to  deprive  the  latter  almost  entirely 
of  significance.  Another  question  is  whether  it  is 
desirable  to  choose  0  '2  per  cent,  salt  solution  as  our 
fluid  basis.  It  has  been  shown  that  distilled 
water  acts,  when  injected,  as  a  powerful  tissue 
irritant.  On  the  other  hand,  physiological  salt 
solution  is,  as  we  know,  entirely  unirritating.  We 
must,  then,  admit  the  strength  of  Braun's  position 
when  he  contends  for  physiological  salt  solution 
as  the  ideal  vehicle  for  anaesthetic  solutions.  If, 
then,  a  method  can  be  devised  in  which  physio- 
logical   salt    solution    constitutes    the   vehicle,   it 


60  LOCAL  ANESTHESIA 

must  certainly  be  preferred  a  priori.  Schleich 
states,  indeed,  that  he  has  performed  a  large 
number  of  operations  under  his  method,  and  has 
never  seen  any  injury  to  tissue  from  it.  No 
surgeon,  however,  finds  all  his  operation  wounds 
heal  by  first  intention.  Who  can  say,  in  many 
cases,  whether  some  slightly  unsatisfactory  con- 
dition about  a  wound  is  to  be  ascribed  to  the 
catgut,  to  some  failure  in  asepsis,  or  perhaps  to 
the  local  anaesthesia  ?  Thus  Bier,  for  instance,  one 
of  the  earliest  advocates  of  Schleich's  method, 
speaks  of  his  fear  that  it  may  cause  injury  to 
tissues  (Surgical  Congress,  1909).  Hocher,  also, 
in  his  latest  teaching  on  operative  surgery, 
expresses  the  same  misgiving.  Probably  in  this, 
as  in  other  methods  to  be  discussed  later,  certainty 
in  this  respect  will  only  be  arrived  at  by  combining 
the  experience  of  many  great  hospital  cliniques. 
We  may  see  a  long  series  of  laparotomies  heal 
without  complications,  and  yet  not  be  justified  in 
deducing  therefrom  the  complete  harmlessness  of 
our  methods  in  all  cases.  It  is  certain,  however, 
that  novocain  is  far  less  dangerous  to  tissues  than 
cocain,  and  we  may  regard  it  as  probable  that  in 
novocain  we  have  approached  a  full  and  satis- 
factory solution  of  the  problem  in  this  regard. 

The  second  point  on  which  Schleich  lays  stress 
appears  to  us  of  greater  significance  than  his 
opponents    admit.     The  ischsemia  caused  by  the 


METHODS  OF  LOCAL  ANESTHESIA  61 

artificially-produced  oedema  is,  if  his  method  is 
correctly  carried  out,  a  very  pronounced  one.  It 
is,  in  my  opinion,  a  powerful  auxiliary,  and  fulfils 
almost  the  same  function  as  suprarenin.  Where 
the  oedema  is  very  marked,  pressure  on  sensory 
nerves  may  also  come  into  play  as  an  auxiliary. 
Difierence  of  temperature — increased  by  cooling 
the  anaesthetic  solution  before  injection — also 
tends  to  heighten  anaesthetic  eftect. 

Where  Schleich's  method  is  correctly  carried 
out,  the  order  of  importance  of  the  difierent  factors 
is  probably  represented  with  sufiicient  accuracy  as 
ibllows  : 

Anaesthetic  (chief  agent). 
Ischaemia  of  tissues  (chief  auxiliary). 
Soaking  of  tissues. 
Pressure  on  nerve-endings. 
Difference  of  temperature. 

Much  of  Schleich's  theory,  then,  cannot  be  up- 
held at  the  present  day.  At  the  same  time,  it  is 
not,  in  my  opinion,  correct  to  ascribe  to  the 
physical  factors  in  Schleich's  method  an  entirely 
subordinate  role.  They  act  as  pow^erful  auxiliaries 
to  the  anaesthetic  itself,  always,  of  course,  assuming 
that  the  method  is  carried  out  strictly  according 
to  Schleich's  directions. 

It  is  quite  another  question  whether  Schleich's 
method  is  to  be  regarded  as  the  method  of  election 


62  LOCAL  ANESTHESIA 

at  the  present  day.  A  disadvantage  quite  distinct 
from  any  we  have  considered  above  is  the  im- 
possibihty  of  distinguishing  the  tissues.  In  many 
operations,  especially  in  infected  tissues,  this  may 
be  of  little  moment ;  in  others,  however,  especially 
where  an  exact  differentiation  between  healthy  and 
diseased  tissues  is  of  the  essence  of  the  operation, 
it  adds  enormously  to  the  surgeon's  difficulties. 
A  further  disadvantage  lies  in  the  fact  that  in 
many  operations  the  anaesthesia  is  not  established 
before  the  first  incision  is  made,  but  it  is  necessary 
during  the  course  of  the  operation  to  infiltrate  the 
deeper  layers,  and  often  to  wait  some  time  for 
anaesthesia  to  develop.  The  operator's  loss  of 
time  is  not  the  only  evil  here,  for,  as  every  surgeon 
knows,  it  is  of  the  first  importance,  in  the  interest 
of  asepsis,  that  operations  shall  be  performed 
quickly,  and,  if  possible,  without  interruption  of 
any  kind.  In  small  operations  this  is  not  of  so 
great  moment  ;  in  the  larger  operative  procedures, 
however,  the  certainty  of  maintaining  asepsis 
undoubtedly  diminishes  as  the  duration  of  the 
operation  increases. 

Finally,  especially  in  the  deeper  regions,  it  is 
impossible  to  count  with  certainty  on  Schleich's 
dilute  solutions  for  the  efficient  anaesthetization  of 
the  larger  nerve-trunks.  This  is  of  special  impor- 
tance in  operations  for  ligature  of  bloodvessels, 
so   that   Schleich    himself  advises  that    in   these 


METHODS  OF  LOCAL  ANESTHESIA  63 

operations  the  nerve-trunks  running  with  the 
arteries  shall  be  previously  dabbed  with  1  in  20  car- 
bolic acid.  This  is  troublesome,  and  requires  time. 
All  this  does  not  in  any  way  diminish  the  great 
merit  of  Schleich's  work.  No  investigator  reaches 
at  a  bound  the  limit  of  the  attainable  in  his  line 
of  discovery.  As,  however,  we  have  to-day,  as  we 
shall  see  in  the  following  sections,  methods  which 
are  free  from  the  disadvantages  presented  by 
Schleich's,  the  latter  will  only  be  employed  when 
these  other  methods  are  for  some  reason  inap- 
plicable. 

4.  "Conduction"  Anaesthesia. 

This  method,  whose  foundations  were  laid  by 
Corning,  has,  during  the  last  few  years,  acquired 
rapidly  growing  importance  from  the  work  of 
Hackenbruch  and  Braun.  By  the  term  "  conduc- 
tion "  anaesthesia  we  understand  a  method  in  which 
a  given  area  of  operation  is  rendered  insensitive  by 
anaesthetizing  the  sensory  nerve-trunks  passing 
from  it,  thus  by  interruption  of  sensory  nerve- 
tracts. 

Two  forms  of  conduction  anaesthesia  may  be  dis- 
tinguished :  (1)  that  caused  by  perineural  injection, 
in  which  the  anaesthetic  is  injected  into  the 
neighbourhood  of  the  nerve  to  be  dealt  with,  and 
reaches  the  nerve  by  diffusion;  and  (2)  that  caused 


64  LOCAL  ANESTHESIA 

by  injection  into  the  nerve  itself  (endoneural). 
The  latter  is  now  hardly  used,  and  we  may  confine 
our  attention  to  the  former. 

Of  considerable  importance  here  is  the  anatomi- 
cal fact  that  the  smallest  and  finest  branchings  of 
the  peripheral  nerves  possess  only  a  very  thin 
sheath,  and  that  this  increases  in  thickness  as  one 
passes  along  the  nerve  in  a  central  direction,  in 
proportion  to  the  increase  in  calibre  of  the  nerve 
itself.  The  thinner  the  sheath  the  more  readily 
can  anaesthetic  solutions  penetrate  it  to  reach  the 
nerve,  interrupting  the  passage  along  the  latter  of 
sensory  impulses.  An  important  principle  follows 
from  the  foregoing,  namely,  that  it  is  more  difficult 
to  interrupt  conduction  in  the  larger  nerve-trunks 
than  in  their  peripheral  branches.  Whenever  it  is 
possible,  therefore,  to  render  insensitive  the  area  of 
a  projected  operation  by  anaesthetizing  the  smaller 
nerve -trunks,  this  simpler  method  is  adopted,  and 
the  larger  nerves  may  be  left  out  of  account. 

The  most  frequently  used  method  of  this  kind  is 
the  so-called  "  circular  anaesthesia "  of  Hacken- 
bruch.  Here  the  tissues  surrounding  the  site  of 
operation  are  thoroughly  infiltrated  with  an  anaes- 
thetic solution,  and  the  conduction  of  afferent 
impulses  thus  cut  off  in  all  the  sensory  nerves 
supplying  the  area. 

Schleich's  method  of  dealing  with  inflamed  areas 
{e.g.y  furuncles)  is,    in    my    opinion,    in    spite    of 


METHODS  OF  LOCAL  ANESTHESIA  65 

Schleich's  expression  of  the  contrary  view,  merely 
a  form  of  conduction  anaesthesia.  He  begins  by 
infiltrating  the  healthy  tissues  round  the  inflamed 
focus,  and  slowly,  with  intervals  sometimes  of 
minutes,  continues  the  infiltration  into  the  in- 
flamed parts.  This  is  nothing  more  nor  less  than 
conduction  ansesthesia,  and  the  latter  part  of  the 
procedure,  the  infiltration  of  the  inflamed  area, 
could  quite  safely  be  omitted,  as  it  becomes 
anaesthetic,  and  often  very  rapidly,  when  the  sur- 
rounding tissues  are  efiiciently  infiltrated. 

The  new  substitutes  for  cocain,  and  the  intro- 
duction of  the  suprarenin  preparations,  have 
enabled  us  to  employ  the  method  of  circular 
anaesthesia  much  more  freely  than  was  formerly 
the  case.  A  freer  range  of  dosage  is  now  permis- 
sible, stronger  solutions  and  larger  quantities  may 
be  employed  than  was  formerly  the  case,  and  thus 
wider  areas  and  larger  nerve-trunks  brought 
under  the  influence  of  the  local  anaesthetic.  We 
inject  now  without  misgiving  as  much  as  50  c.c.  of 
1  per  cent,  novocain  solution,  while  the  quantity 
of  cocain  required  to  produce  about  the  same 
eflect — viz.,  50  c.c.  of  a  0'5  per  cent,  solution — is  far 
beyond  the  limit  of  safety.  Thus,  for  instance, 
the  performance  of  an  operation  on  strumous 
fj-lands  under  local  anaesthesia,  which  was  formerlv 
a  diflicult  and  doubtful  proceeding,  is  now  simple, 
and  as  a  rule  absolutely  safe. 

5 


66  LOCAL  ANESTHESIA 

Where  circular  ancesthesia  is  applicable,  we 
must  endeavour  to  interrupt  conduction  in  the 
larger  nerve-trunks  by  perineural  injection.  In 
the  case  of  some  nerves  this  method  is  both  simple 
and  sure  {e.g.,  nerves  of  the  fingers) ;  in  others 
(nerviis  alveolaris  inferior),  it  is  not  simple,  but  when 
the  technique  is  mastered,  it  is  fairly  sure.  In  others, 
again,  as,  for  instance,  the  nerves  of  the  forearm,  it 
is  not  to  be  relied  on,  and  is  beginning  to  be  re- 
placed by  other  methods.  The  best-known  method 
of  conduction  anaesthesia  by  perineural  injection  is 
that  bearing  Oberst's  name.  It  is  used  in  opera- 
tions on  the  fingers  and  toes.  After  injection, 
which  is  carried  out  in  the  manner  described 
below,  the  base  of  the  digit  is  found  to  become 
anaesthetic  first,  the  anaesthesia  then  gradually 
spreading  towards  the  periphery.  This  fact  might 
easily  lead  the  unskilled  observer  to  infer  that  the 
anaesthetic  slowly  diffuses  in  the  bloodless  member 
towards  the  periphery,  and  that  the  whole  process 
is  a  centrifugal  one.  We  know,  however,  that 
conduction  of  sensory  impulses  is  much  more 
readily  interrupted  in  the  finer  than  in  the  larger 
nerve-trunks.  Thus  the  skin  of  the  digital  per- 
iphery, which  contains  the  terminal  ramification  of 
the  nerve-trunks  which  at  the  base  of  the  finger 
are  of  substantial  calibre,  is  the  last  to  become 
anaesthetic,  while  the  skin  at  the  base  is  supplied 
by  fine  nerve-trunks  running,  at  the  point  of  in. 


METHODS  OF  LOCAL  ANAESTHESIA  67 

jection,  side  by  side  with  the  main  trunks,  and 
these  lose  their  sensitiveness  to  pain  very  soon 
after  the  injection.  Diffusion,  as  a  matter  of  fact, 
plays  but  a  small  part  in  the  development  of  this 
form  of  anaesthesia,  as  can  be  seen  by  noticing  the 
whitening  of  the  skin  in  a  direction  from  centre  to 
periphery,  when  a  somewhat  larger  dose  of  supra- 
renin  than  usual  is  added  to  the  anaesthetic. 

Ligature  of  the  digit  at  the  base  is  no  longer 
necessary  in  Oberst's  method.  The  finger  can  be 
anaesthetized  with  certainty  by  a  2  per  cent, 
novocain  solution  +  suprarenin. 

Endoneural  injection  is,  as  we  have  stated  above, 
hardly  employed  at  the  present  day.  Formerly  a 
certain  number  of  major  operations,  especially 
amputations,  were  performed  under  it,  the  larger 
nerve-trunks  being  first  exposed  under  Schleich's 
infiltration  anaesthesia,  and  then  directly  injected 
with  concentrated  cocain  solutions.  This  compli- 
cated method  is  now  practically  abandoned.  Even 
before  the  introduction  of  Bier's  venous  ances- 
thesia,  most  surgeons  chose  in  preference  to  it 
either  general  or  spinal  anaesthesia. 

In  operations  on  inguinal  hernias,  a  method 
introduced  by  Gushing  has  been  frequently  em- 
ployed, in  which  endoneural  injections  are  admin- 
istered after  exposure  of  the  nerves  of  the  inguinal 
region.  This  is  now  superseded  by  another 
method,  in  which  the  whole  quantity  of  anaesthetic 


68  LOCAL  ANESTHESIA 

solution  is  injected  before  the  commencement  of 
the  operation,  and  the  operator  is  thus  enabled 
to  work  quickly  and  surely. 

It  is  beyond,  question  that  the  method  of  con- 
duction anaesthesia  possesses  very  real  advantages 
over  Schleich's  m^ethod.  As  the  chief  of  these  I 
should  place  the  possibility,  especially  in  major 
aseptic  operations,  of  carrying  out  the  operation 
quickly  and  w^ithout  anxiety  about  the  anaesthetic, 
and,  further,  the  completeness  of  the  anaesthesia, 
and  the  fact  that  the  parts  operated  on  retain 
their  normal  anatomical  conditions,  and  the 
operator  is  thus  enabled  to  distinguish  clearly  the 
boundary  lines  of  the  different  tissues.  Another 
advantage  is  the  lessened  risk  of  injury  to  the 
tissues.  There  are,  however,  whole  classes  of 
operations  to  which  the  method  of  conduction 
anaesthesia  is  not  applicable,  and  in  which  Schleich's 
method,  generally  somewhat  modified,  still  holds 
its  ground. 

5.  Venous  Anesthesia. 

This  latest  advance  in  methods  of  local  anaes- 
thesia was  first  described  by  Bier  before  the 
Surgical  Congress  of  1908. 

While,  as  we  have  seen,  it  is  difiicult  to  anaes- 
thetize the  larger  nerve  -  trunks  by  perineural 
injections,  owing  to  the  thickness  of  their  con- 
nective-tissue covering,  Bier  succeeded,  by  inject- 


METHODS  OF  LOCAL  ANESTHESIA  69 

ing  ansesthetic  solutions  under  pressure  into  the 
veins  of  a  limb  between  two  tourniquets,  in 
securing  the  penetration  of  the  solution  into  all 
the  tissues  of  the  involved  area,  including  the 
protective  sheath  of  the  nerves,  and  this  rapidly 
and  with  a  completeness  unknown  under  any 
previous  method. 

Bier  was  able  to  demonstrate  this  experi- 
mentally on  amputated  limbs  by  injecting  an 
indigo-carmine  solution  into  the  veins.  Careful 
examination  shortly  after  the  injection  showed 
that  the  tissues  were  traversed  in  every  direction 
by  blue  tinted  capillaries,  even  the  bone  marrow 
sharing  in  the  general  blue  coloration.  (Doubt  was 
thrown  at  first  on  Schleich's  statement  that  the 
bone  marrow  could  be  infiltrated  by  injecting  the 
periosteum.  The  possibility,  however,  of  infil- 
trating the  medulla  by  way  of  venous  injection 
proves  the  correctness  of  his  observation.)  In  the 
living  subject  the  section  of  the  limb  enclosed 
between  the  two  tourniquets  becomes  anaesthetic 
almost  immediately  after  the  injection  of  the  solu- 
tion (i  per  cent,  novocain  solution),  under  pressure 
(direct  ancesthesia).  Somewhat  later  the  portion 
of  the  limb  beyond  the  distal  tourniquet  also 
becomes  anaesthetic  (indirect  ancesthesia).  There 
is  practically  no  risk  of  general  poisoning  in 
venous  anaesthesia.  The  only  untoward  symptom 
observed  by  Bier  has  been  nausea,  which  he  has 


70  LOCAL  ANESTHESIA 

seen  once  in  a  child  of  seven  and  once  in  a  woman 
of  sixty  after  removal  of  the  tourniquets. 

The  doses  employed:  60  to  100  c.c.  of  J  per 
cent,  novocain  solution — are  by  no  means  large. 
Of  chief  importance,  however,  is  the  certainty  that 
the  novocain,  being  distributed  to  every  part  and 
tissue  of  the  affected  area,  will  enter  into  com- 
bination with  the  tissue  protoplasm,  and  thus  lose 
its  poAver  of  causing  general  poisoning. 

Bier  adopts  special  precautions  only  when  he 
administers  large  doses  to  children.  The  pre- 
cautions he  adopts  are  as  follows  : 

1.  After  removal  of  the  tourniquet  it  is  re- 
applied for  a  time  and  then  finally  removed.  This 
insures  the  passage  of  the  drug  in  two  portions 
into  the  general  circulation,  with  an  interval  of 
time  between. 

2.  The  cannula,  which  is  furnished  with  a  stop- 
tap,  is  left  in  the  vein  until  the  operation  is 
finished  and  it  is  time  to  apply  the  sutures. 
Warm  physiological  salt  solution  is  then  injected, 
so  as  to  wash  out  any  excess  of  the  anaesthetic. 

How  far  there  exist  risks  of  injury  to  tissue 
which  might  contra-indicate  the  use  of  venous 
anaesthesia,  only  prolonged  experience  can  show. 
In  amputations  for  diabetic  or  senile  gangrene 
Bier  has  several  times  observed  abnormalities  in 
the  behaviour  of  the  wounds  which  might  possibly 
be   ascribed   to   the   anaesthetic.       He    therefore 


METHODS  OF  LOCAL  ANAESTHESIA  71 

advises  against  the  use  of  the  method  in  such 
cases. 

In  one  patient,  a  woman,  motor  paralysis  of  the 
hand  followed  an  operation  under  venous  anaes- 
thesia. The  paralysis  disappeared  in  the  course 
of  four  weeks.  Bier  considered  that  the  paralysis 
was  of  the  same  nature  as  that  sometimes  seen 
after  adninistration  of  a  general  anaesthetic.  The 
latter,  however,  only  appears  when  the  arm  and 
shoulder  iiave  been  kept  during  the  operation  in 
an  abnormal  position,  such  as  would  not  occur  or 
be  maintained  during  venous  anaesthesia. 

Air-bubtles  have  several  times  been  seen  in  the 
veins.  No  symptoms  of  embolism,  however,  have 
followed  their  appearance. 

Out  of  lc'4  operations.  Bier  has  had  115  good, 
14  satisfactory  results,  and  5  failures.  With 
increasing  sureness  of  technique  failures  will 
gradually  come  to  be  avoided  altogether. 

The  direci  anaesthesia,  that,  namely,  affecting 
the  section  of  the  limb  between  the  two  tourni- 
quets, comes  on  immediately  in  the  smaller  and 
medium  sized  nerves.  The  saturation  of  the  larger 
nerve-trunks  requires  some  minutes  (up  to  five 
minutes  in  tlie  larger  limbs).  The  more  complete 
is  the  removal  of  blood  from  the  parts  involved 
the  quicker  is  the  development  of  anaesthesia. 
Irregularities  in  these  respects  are,  however, 
observed  occasionally. 


72  LOCAL  ANAESTHESIA 

The  rapidity  with  which  indirect  angesth^ia 
— that  affecting  parts  peripheral  to  the  d/stal 
tourniquet — comes  on  varies  very  much.  The 
onset  may  be  almost  immediate,  or  there  rpay  be 
a  delay  of  as  much  as  twenty  minutes.  Simul- 
taneously with  the  development  of  indirect  anses- 
thesia  there  is  noticed  a  weakness  of  the  muscles, 
which  is  soon  followed  by  complete  paralysis. 
This  motor  paralysis  is  a  sign  that  the  indirect 
anaesthesia  is  complete,  and  that  the  Operation 
may  therefore  be  begun. 

The  deeper  parts  are,  according  to  Bier,  more 
rapidly  involved  in  the  anaesthesia  tha^  the  more 
suj^erficial.  / 

The  so-called  indirect  anaesthesia  is  a  conduc- 
tion anaesthesia,  determined  by  an  interruption  of 
conduction  in  the  larger  nerve-trunks.  It  spreads 
from  the  centre  (distal  tourniquet)  to  tlie  periphery. 

Bier  has  abandoned  the  addition  of  suprarenin 
preparations.  "While  in  some  cases  they  had  some 
effect  in  deepening  and  prolonging  anaesthesia,  in 
others  they  failed  completely.*  Petrow  also  has 
only  occasionally  noticed  any  prolongation  of 
anaesthesia  from  the  addition  of  suprarenin. 

The  chief  drawback  to  venous  anaesthesia  is  its 
rapid  disappearance  (two  to  seven  minutes)  after 
removal  of  the  tourniquets.  This  makes  the  arrest 

"^^  The  uncertain  eflfects  of  the  earlier  suprarenin  prepara- 
tions may  have  been  a  factor  here.  ; 


METHODS  OF  LOCAL  ANESTHESIA  73 

of  hsemorrhage  a  difficult  process  and  its  painless- 
ness not  sufficiently  certain.  We  may  hope,  how- 
ever, to  succeed  before  long,  perhaps  with  the  aid 
of  sujDrarenin  preparations,  in  overcoming  this 
difficulty. 

In  any  case  venous  anaesthesia  represents  cer- 
tainly an  important  step  forward  in  the  practice 
of  local  ansesthesia.  On  the  one  hand,  certain 
operations  which  could  only  be  carried  out  imper- 
fectly and  with  difficulty  under  conduction  anaes- 
thesia {e.g.,  operations  on  the  hand  after  perineural 
injections  round  the  nerves  of  the  forearm),  can 
now  be  performed  safely  and  surely  under  venous 
anaesthesia ;  while,  on  the  other,  the  larger  opera- 
tions on  the  extremities — amputations,  resections, 
etc. — have  lost  som.e  of  the  dangers  involved  in 
general  or  spinal  anaesthesia.  Whether  and  to 
what  extent  special  contra-indications  will  manifest 
themselves  it  is  impossible  now  to  say.  It  is 
probable  that  wider  experience  will  show  the 
necessity  of  using  the  method  but  sparingly  where 
septic  processes  are  present  or  the  nutrition  of  the 
affected  part  is  already  interfered  with. 

As  a  further  disadvantage  must  be  mentioned 
the  somewhat  complicated  technique  of  venous 
anaesthesia. 


74  LOCAL  ANESTHESIA 

Arterial  Anesthesia. 

For  the  sake  of  completeness  mention  may  be 
made  of  some  experiments  of  Goyanes  and  Oppel, 
who  have  brought  about  an  arterial  anaesthesia  in 
animals  by  injecting  cocain  into  the  arteries. 
Oppel,  for  instance,  found  that  he  could  inject 
eight  to  ten  times  as  much  cocain  into  the  aorta 
as  into  the  vena  cava  inferior,  and  deduces  from 
this  fact,  fallaciously  in  my  opinion,  the  superiority 
of  arterial  anaesthesia.  The  cocain  is,  he  thinks, 
neutralized  in  the  arterio-capillary  area.  Goyanes 
has  twice  employed  this  form  of  anaesthesia  in  the 
human  subject.  It  is  hardly  probable  that  these 
experiments  will  lead  to  results  of  much  impor- 
tance. Though  the  introduction  of  an  anaesthetic 
into  the  arteries  is  in  itself  quite  feasible,  the 
situation  of  the  arteries  is  such  as  to  necessitate 
for  that  purpose  a  somewhat  complicated  pre- 
liminary operation,  and  it  is  for  this  reason  un- 
likely that  the  method  can  compete  seriously  with 
the  relatively  simple  method  of  venous  anaesthesia. 


CHAPTER  VI 

GENERAL  TECHNIQUE 

Preliminary  Remarks. 

In  general,  local  anaesthesia  should  only  be  em- 
ployed in  cases  where  it  is  possible  to  attain 
complete  local  insensibility  to  pain.  This  rule 
should  only  be  departed  from  in  cases  of  absolute 
necessity,  that  is  to  say,  when  general  anaesthesia 
involves  so  great  a  risk  to  the  patient's  life  as  to 
forbid  its  employment.  Everyone  must  expect 
failures  at  the  commencement.  The  surgeon  should 
candidly  ascribe  such  failures  to  his  own  faulty 
technique  or  the  imperfection  of  our  methods,  and 
should  not  seek  forcibly  to  persuade  his  patient 
and  himself  that  the  former  felt  no  pain.  There 
are,  of  course,  patients  whose  anticipation  and 
fear  of  pain  is  such  that  they  cry  out  and  betray 
extreme  excitement  throughout  an  operation,  and 
yet  confess  afterwards  that  they  felt  nothing  ; 
for  such  patients  local  anaesthesia  is  unsuitable, 
and  a  general  anaesthetic  should  be  employed ; 
for  the  terror  they  endure  during  the  whole  pro- 
cedure must  involve  hardly  less  suffering  than  the 

75 


76  LOCAL  ANESTHESIA 

actual  pain  of  an  operation.  One  must  not  be 
fanatical  in  one's  advocacy  of  local  anaesthesia. 
If  it  is  not  discredited  by  being  used  in  unsuitable 
cases  or  by  faulty  technique,  it  will  gradually  gain 
in  popularity,  and  cases  such  as  that  cited  above 
will  become  rarer  when  patients  can  come  to  their 
surgeon  for  au  operation  with  the  absolute  cer- 
tainty of  the  operation  being  painless.  Even 
to-day  patients  frequently  come  to  us  with  the 
request  that  they  may  be  operated  on  under  local 
anaesthesia,  and  not  be  rendered  insensible  by  a 
general  anaesthetic. 

Suggestions  for  a  "combined  anaesthesia,"  that 
is,  for  the  auxiliary  employment  of  a  general 
anaesthetic  during  certain  sj)ecially  painful  parts 
of  the  operative  procedure,  are,  in  my  opinion,  not 
to  be  commended.  Here,  again,  exception  may 
be  made  in  respect  of  cases  in  which  for  special 
reasons  narcosis  must,  as  far  as  possible,  be 
avoided.  In  such  cases  a  brief  ether  or  chloroform 
narcosis  may  be  used  in  reinforcement  of  local 
anaesthetic  methods,  as  for  instance  in  a  laparotomy, 
when  at  one  stage  traction  must  be  made  on  the 
mesentery.  Otherwise,  one  should  allow  the 
patient  the  assurance  of  an  absolutely  painless 
operation,  and  should  avoid  exaggerating  the 
dangers  of  general  anaesthesia. 

In  passing  to  the  consideration  of  general 
technique  we  would  lay  down  at  the  outset,  as  a 


GENERAL  TECHNIQUE 


77 


foundation  principle,  that  it  should  be  as  simple  as 
possible.  We  purposely  avoid  descriptions  alike 
of  complicated  injection  apparatus  and  of  compli- 
cated anaesthetic  solutions.  The  object  aimed  at 
is  to  describe  methods  in  such  a  manner  that  they 
may  be  applied  as  readily  by  the  practical  coTintry 
doctor,  as  in  a  large  surgical  clinique 
furnished  with  every  modern  aux- 
iliary and  appliance. 

The  syringe  I  have  found  by 
prolonged  trial  to  be  most  satisfac- 
tory is  a  glass  syringe  Avith  a  metal 
piston,  which  can  be  completely 
withdrawn  from  the  glass  cylinder.  "'^' 
The  syringe  is  boiled  each  time 
before  use,  either  in  water,  physio- 
logical salt  solution,  or  soda  solution. 
In  the  latter  case  it  must  be  washed 
through  before  use  with  sterilized 
water  or  salt  solution,  as  soda 
irritates  the  tissues  and  lessens  the 
effect  of  anaesthetic  drugs,  and  ^^^-  ^• 
especially  of  suprarenin  preparations.  Before 
boiling,  the  syringe  must  be  taken  apart.  The 
cylinder  must  not,  of  course,  be  plunged  suddenly 
into  boiliug  water,  as  this  would  involve  great  risk 
of  breakage.  From  the  moment  boiling  commences 
the  parts  should  be  left  in  the  boiling  water  for 
five  minutes.  On  withdrawal  from  the  water  the 
*  The  so-called  ''  Record  "  syringe. 


78 


LOCAL  ANESTHESIA 


metal  cylinder  must  first  be  cooled,  otherwise  it 
will  be  found  impossible  to  introduce  it  into  the 
cylinder.  For  those  who  only  occasionally  employ 
local  anaesthesia  syringes  of  2  and  10  c.c.  capacity 
are  the  most  generally  useful.     Those  who  use  it 

frequently  should  be  sup- 
plied with  syringes  of  1, 
2,  5,  and  10  c.c.  capacity. 

A  supply  of  needles  of 
various  lengths  and  cali- 
bres should  be  at  hand, 
including,  perhaps,  a  few 
curved  ones,  though  I  have 
so  far  not  found  it  neces- 
sary to  employ  the  latter. 
The  best  are  platino- 
iridium  needles,  which, 
though  more  costly  than 
steel  ones,  are  more  dur- 
able, do  not  rust,  and  can 
be  made  red-hot  without 
injury.  It  is,  of  course,  a  great  advantage  in 
practice  that  all  his  needles  should  fit  every  size 
of  syringe  used  by  the  surgeon. 

After  use  all  parts  must  be  well  dried  and  the 
needles  washed  through  with  absolute  alcohol.  It 
is  advisable  also  to  wash  through  the  nozzle  of  the 
syringe  in  a  similar  manner  in  order  to  remove 
water  completely.     The  needles  should  have  a  wire 


Fig.  4. 


GENERAL  TECHNIQUE  79 

passed  through  their  barrel  before  being  put  away. 
It  is  advisable  to  smear  the  metal  parts  of  the 
syringe  with  a  drop  of  paraffin  to  prevent  rust. 

For  his  method  of  venous  anaesthesia  Bier  em- 
ploys a  syringe  of  about  100  c.c.  capacity  (Fig.  4). 
It,  too,  has  a  metal  piston  working  in  a  glass  cylin- 
der. A  thick-walled  rubber  tube  can  be  fitted  by  a 
screw  attachment  to  the  nozzle  of  the  syringe,  the 
other  end  of  the  tube  being  connected  with  the  in- 
jection cannula  by  a  bayonet  fastening.  The  whole 
apparatus  is  thus  very  readily  put  together  and 
taken  apart  again.  The  injection  cannula  is  fitted 
with  a  tap,  which  prevents  leakage  of  solution.  The 
cannulas  employed  are  as  thin  walled  as  possible. 
Near  their  termination  are  two  circular  grooves  to 
facilitate  the  process  of  tying  into  the  vein.  The 
syringe  must  be  boiled  only  in  physiological  salt 
solution,  not  in  alkaline  solutions,  otherwise  the 
rules  given  above  for  the  use  and  management  of 
injection  syringes  apply  here  also. 

As  regards  solutions,  it  is  advisable  for  any 
surgeon  who  operates  much  under  local  anaesthesia 
to  have  a  supply  of  both  1  per  cent,  and  2  per 
cent,  solutions  of  novocain  in  physiological  salt 
solution  always  dt  hand. 

The  physiological  salt  solution  is  sterilized  in 
^  or  1  litre  flasks,  preferably  in  a  water-bath, 
the  flasks  themselves  having  been  previously  steri- 
lized by  boiling.     The  flasks  are  best  closed  by  an 


80  LOCAL  ANESTHESIA 

india-rubber  cork  or  a  wad  of  sterile  muslin.  The 
novocain  solution  is  kept  in  ordinary  medicine 
bottles  in  quantities  of  100  grammes,  or,  in  the  case 
of  2  per  cent,  solutions,  of  50  grammes.  Bottles 
and  stoppers  must  be  sterilized.  The  novocain 
solution  is  shaken  up  in  the  bottle,  and  the  sterile 
physiological  salt  solution  is  added  gradually  ;  the 
whole  requires  then  only  a  short  boiling  in  a  water- 
bath.  Before  use,  if  one  is  not  certain  that  the 
solution  is  still  sterile,  it  should  be  heated  to 
100°  C.  in  a  water-bath  for  five  minutes,  or  the 
required  quantity  can  be  raised  to  boiling-point 
in  a  sterile  test-tube.  The  amount  required  for 
use  is  then  poured  into  a  sterilized  graduated  glass 
cylinder  of  about  50  c.c.  capacity,  and  from  this 
into  a  sterilized  glass  dish  (all,  of  course,  boiled  in 
soda-free  solutions).  Suprarenin  is  added  imme- 
diately before  the  solution  is  to  be  used.  It  is 
kept  only  in  small  bottles  holding  5  c.c.  Supra- 
renin solutions  that  are  not  absolutely  clear  should 
on  no  account  be  used.  It  is  advisable  also  to  re- 
ject any  bottles  that  have  been  kept  for  any  con- 
siderable time  since  opening.  After  the  first  use 
the  rubber  stopper  should  be  replaced  by  an 
ordinary  cork.  In  the  case  of  major  aseptic  opera- 
tions it  is  better  to  take  the  solution  from  a 
previously  unopened  bottle. 

Those  who  make  only  occasional  use  of  local 
anaesthesia  will  find  Braun's  novocain  suprarenin 


GENEKAL  TECHNIQUE  81 

tablets  suitable  and  useful.  They  are  simply  dis- 
solved before  use  in  a  given  quantity  of  sterile 
physiological  salt  solution.  Any  of  the  solution 
that  may  remain  over  after  use  should  be  thrown 
away ;  it  should  on  no  account  be  used  again.  I 
personally  prefer  to  add  the  suprarenin  imme- 
diately before  the  operation,  as  I  have  several 
times  observed  a  rose  tint  to  develop  on  dissolving 
the  tablets  in  warm  water. 

Two  tablets  are  manufactured  : 


Tablet  A. 

Novocain,  0'1:^5  gramme;  suprarenin,  O'OOOIG 
gramme.  This  tablet  dissolved  in  5 0  c.c.  gives  5 0  c. c. 
of  a  0*25  per  cent,  novocain  solution -1-5  drops  of 
suprarenin  (Solution  L). 

Twenty-five  c.c.  gives  25  c.c.  of  a  0'5  per  cent, 
novocain  solution  4-5  drops  of  suprarenin  (Solu- 
tion 11. ). 

Tablet  B. 

Novocain,  O'l  gramme;  suprarenin,  0 '00045. 
This  tablet  dissolved  in  10  c.c.  gives  10  c.c.  of  a 
1  percent,  novocain  solution  +  10  minims  of  supra- 
renin (Solution  III.). 

Five  c.c.  gives  5  c.c.  of  a  2  per  cent,  novocain 
solution  +  10  minims  of  suprarenin  (Solution  IV.). 

6 


82  LOCAL  ANESTHESIA 

Solutions  II.  and  IV.  can  be  obtained  ready 
prepared  in  small  bottles  or  ampullae,  and  Solu- 
tions I.  and  III.  can  be  prepared  by  simple  dilu- 
tion with  an  equal  volume  of  physiological  salt 
solution.  It  is  still  a  disputed  point  whether  or 
no  the  tablets  are  sterile.  Until  just  recently  it 
has  been  impossible  to  boil  their  solutions,  as  the 
suprarenin  they  contain  is  not  the  synthetic  form. 
Lately,  in  view  of  the  fact  that  the  ready  decom- 
posibility  of  the  suprarenin  is  due  to  the  presence 
of  traces  of  alkali  (in  the  glass  vessels  ?),  Braun 
has  recommended  that  officinal  dilute  hydro- 
chloric acid  be  added  to  the  physiological  salt  used 
for  dissolving  the  tablets,   in  the  proportion  of 

1  minim  to  the  litre.  The  solution  can  then 
safely  be  boiled  before  use. 

To  dentists  who  employ  almost  always  the  same 
strength  of  solution,  ampullae  containing  1  c.c.  of 

2  j)er  cent,  novocain  solution  +  1  minim  of  supra- 
renin may  be  recommended  as  useful  and  con- 
venient. 

The  1  per  cent,  solution  of  novocain  is  the  one 
I  generally  employ  in  minor  surgery.  The  2  per 
cent,  solution  is  only  used  for  interrupting  con- 
duction in  nerve-trunks  of  some  size,  especially  in 
operations  on  the  teeth  and  fingers.  In  all  opera- 
tions in  which  more  than  50  c.c.  of  the  solution 
has  to  be  injected  I  use  the  O'o  per  cent,  instead  of 
the  1  per  cent,  solution.     If  more  than  100  c.c.  is 


GENERAL  TECHNIQUE  83 

required,  I  make  the  additional  infiltration  with 
0*25  per  cent,  solution.  Of  suprarenin — I  always 
use  the  1  in  1,000  solution  of  Suprareninum  L.  Syn- 
theticum — I  add,  in  most  operations,  1  to  4  minims 
to  each  10  c.c.  of  the  anaesthetic  solution,  fixing  the 
maximum  quantity  of  suprarenin  to  be  injected  at 
from  15  to  20  minims.  Only  where  large  nerve- 
trunks  have  to  be  anaesthetized  do  I  add  a  larger 
percentage  of  suprarenin  to  2  per  cent,  anaesthetic 
solutions — e.g.,  from  1  to  2  minims  to  each  cubic 
centimetre.  As  only  small  quantities  of  solution 
are  here  employed,  this  larger  percentage  of  supra- 
renin may  be  added  without  misgiving. 

When,  in  the  following  pages,  nothing  is  said 
about  the  dosage  of  suprarenin,  the  rules  already 
laid  down  on  the  matter  must  be  taken  as  apply- 
ing. Those  more  practised  in  local  anaesthesia 
will  not,  however,  follow  them  too  rigidly,  but 
will  suit  the  dose  to  the  individual  case  in  accord- 
ance with  the  amount  of  blood  in  the  tissues,  the 
nutritional  condition  of  the  latter,  and  so  on. 

If  the  method  of  Schleich  is  carried  out  rigidly 
and  the  tissues  so  thoroughly  infiltrated  in  layers 
that  they  appear  to  have  undergone  a  simultaneous 
soakage,  it  is  advisable  either  to  omit  the  addition 
of  suprarenin  altogether,  or  to  add  only  small 
doses  (1  minim  to  10  c.c.  as  a  maximum),  as  the 
anaemia  caused  by  the  artificial  cjedema  acts  as  an 
auxiliary  to  the  anaesthetic.     In  small  operations 


84  LOCAL  ANESTHESIA 

one  may  use  0*5  per  cent,  novocain  solution  with 
confidence.  For  larger  operations  0*25  per  cent, 
solution  should  be  employed. 

It  is,  however,  often  advisable  to  modify  slightly 
Schleich's  technique,  and  avoid  producing  a  maxi- 
mum degree  of  oedema,  though  the  tissues  should 
always  be  freely  permeated  by  the  injected  solu 
tion.  In  small  operations  we  then  employ  1  per 
cent.,  and  in  larger  0*5  per  cent.,  solutions,  with  or 
without  the  addition  of  the  dose  of  suprarenin  given 
above.  It  is  not  then  necessary  to  dab  the  larger 
nerve-branches  specially  with  phenol  solution  ;  the 
concentrated  novocain  solution  will  soon  render 
them  anaesthetic,  though  a  certain  time  must 
always  be  allowed  for  this  effect  to  develop.  We 
shall  also,  when  the  infiltration  method  has  to  be 
employed,  infiltrate  as  many  of  the  tissue  layers 
as  possible  before  the  operation,  wait  for  a  time, 
and  then  carry  out  the  operative  procedures,  if 
possible,  without  a  break.  A  thorough  infiltration 
of  the  subcutaneous  cellular  tissue  renders  super- 
fluous any  special  infiltration  of  the  skin  itself. 

In  conduction  ansesthesia,  also,  it  is  often  advis- 
able to  infiltrate  the  tissues  pretty  thoroughly 
wath  anaesthetic  solution.  This,  how^ever,  does 
not  apply  in  the  case  of  ana3sthetizafcion  of  the 
larger  nerve-trunks  by  concentrated  (2  per  cent.) 
solutions.  While  in  Schleich's  method  the  opera- 
tion is  commenced  immediately  after  the  infiltra- 


GENERAL  TECHNIQUE  85 

tion  of  the  tissues,  in  conduction  anaesthesia,  on 
the  other  hand,  some  considerable  time  must 
often  be  allowed  to  elapse  between  the  comple- 
tion of  the  infiltration  and  the  commencement  of 
the  operation,  it  being  essential  to  success  in 
this  method  to  wait  a  sufiicient  time  to  allow  of 
the  development  of  a  completely  anaesthetic  con- 
dition. Many  a  failure  is  to  be  attributed  to 
the  impatience  of  the  operator.  There  need  be 
no  fear  of  letting  the  right  moment  pass,  for  the 
anaesthesia  produced  with  the  aid  of  suprarenin 
lasts  a  considerable  time.  No  general  rule  can 
be  laid  down  as  to  the  time  that  must  be  allowed 
after  the  injection.  This  depends  on  the  calibre 
of  the  nerve-trunks  involved,  the  strength  of  the 
solution  used,  and  other  factors.  Often,  especi- 
ally in  small  operations  on  the  face  or  head, 
complete  anesthesia  becomes  established  almost 
immediately  after  the  injection.  After  injection 
in  the  neighbourhood  of  the  inferior  alveolar 
nerve  it  is  often  necessary  to  wait  half  an  hour 
for  the  onset  of  anaesthesia.  It  is,  for  reasons 
already  given,  especially  important  to  avoid,  if 
possible,  injecting  into  inflamed  tissues.  Occa- 
sional exceptions  to  this  rule  will  be  considered 
later. 

As  regards  the  technique  of  the  actual  injec- 
tion, the  risk,  though  a  slight  one,  of  injecting 
into  a  vein  must  be  kept  in  mind.     It  is  a  good 


86  LOCAL  ANESTHESIA 

plan  to  move  the  needle  backwards  and  forwards 
continually  during  the  injection.  The  syringe 
may  be  withdrawn  from  the  needle  after  the 
puncture  is  made,  and  the  operator  may  thus 
assure  himself  that  no  blood  passes  out  through 
the  needle. 


Technique  of  Bier's  Venous  Anesthesia. 

The  solution  is  injected  into  a  vein  lying  in  a 
section  of  a  limb,  which  is  cut  off  from  the 
general  blood-stream  by  two  tourniquets.  The 
tourniquets  may,  for  example,  be  applied  above 
and  below  the  elbow-joint,  and  the  injection  be 
made  into  the  vena  basilica  at  the  level  of  the 
joint. 

The  part  of  the  limb  between  the  tourniquets 
must  be  rendered  as  bloodless  as  possible.  As  a 
rule  the  blood  is  expelled  from  the  limb  by  an 
Esmarch  bandage,  applied  up  to  the  level  of  the 
central  tourniquet.  If,  owing  to  the  presence 
of  an  infectious  process,  this  is  not  possible,  the 
peripheral  tourniquet  is  a|)plied  above  the  infected 
area,  and  the  blood  then  expelled  from  the  level 
of  the  peripheral  to  that  of  the  central  tourniquet. 
The  central  tourniquet  is  applied  a  little  above 
the  area  of  operation,  and  is  not  bound  more 
tightly  round  the  limb  than  is  necessary.  The 
pressure    of    the    tourniquet    is   not    as    a    rule 


GENERAL  TECHNIQUE  87 

unpleasantly  felt  after  the  injection.  We  have, 
however,  known  patients  to  complain  of  the 
pressure  throughout  the  operation.  It  is  advis- 
able, therefore,  to  inject  at  a  point  as  near  as 
possible  to  the  upper  (central)  tourniquet ;  the 
vein  may  also  be  exposed  before  the  tourniquets 
are  applied.  The  tourniquets  are  kept  in  phenol 
solution  after  aseptic  operations,  otherwise  they 
are  sterilized  by  boiling. 

The  exposure  of  the  vein  is  carried  out  under 
infiltration  ana3sthesia  with  the  same  0*5  per  cent, 
solution  that  is  used  for  the  injection.      If  the 
search  for  the  vein  is  carried  out  before  the  parts 
have  been  rendered  bloodless,  it  is  advisable  to 
add   a   little    suprarenin   to    the   solution.      The 
subcutaneous    cellular   tissue    must    also   in   this 
case   be  thoroughly  infiltrated.     If  the  vein   is 
sought  for  under  bloodless  conditions,  its  position, 
rendered  plain  by  obstructing  the   venous  flow, 
must  be  marked  before  the  tourniquet  is  applied. 
A  diagonal   incision  is    made   through  the  skin. 
In  obese  subjects  the  vein  is  often  concealed  by 
masses  of  fatty   tissue.     When   the  vein  is  ex- 
posed, a  silk  thread  is  passed  round  it  by  means 
of  a  Deschamps'  needle,  and  the  vein  thoroughly 
exposed  and  freed  for  a  distance  of  about  2  centi- 
metres.    If  there  is  much  scar  formation,  the  vein 
must,  in  view  of  the  possibility  of  obliteration,  be 
sought  for  well  above  the  scar.     In  the  leg  the 


88 


LOCAL  ANAESTHESIA 


N.  saphenus 


Fig.  5.  Fig.  6. 

Course  of  the  Veins  in  the  Lower  Extremity, 


GENERAL  TECHNIQUE 


89 


V.  basilica 

and  N,  cutaneus 

antebrachii 


V.  mediaiia 


great  saphenous  vein  is  the  one  most  frequently 
injected  in  practice  (Figs.  5  and  6).  ^.. 

Its  course  is  depicted  in  the  figure. 
It  arises  from  the   middle  of  the 
venous  network  on  the  dorsum  of 
the  foot,  and  then  passes  in  front 
of  the  inner  malleolus  to  the  inner 
side  of  the  leg,  where  it  is  accom- 
panied by  the  saphenous         y.  cephaiica 
nerve.   It  then  runs  along 
the  inner  side  of  the  knee- 
joint,  passing  behind  the 
inner     condyle     of     the 
femur,  after  which  it  again  comes 
forward,  coursing  along  the  inner 
and  anterior  surface  of  the  thigh 
to  the  saphenous  opening,  where 
it  ends  in  the  femoral  vein. 

In  the  arm  (Fig.  7)  the  veins 
used  as  a  rule  for  injection  are  the 
cephalic  and  basilic  veins  in  the 
lower  half  of  the  arm.  The  por- 
tion of  the  cephalic  vein  with 
which  we  are  concerned  lies,  ac- 
cording to  Bier,  in  front  of  the 
sulcus  bicipitalis  lateralis,  on  the 
outer  side  of  the  biceps.  The 
Vjasilic  vein  lies  in  the  sulcus  hicipi- 
talis  internus ;  the  accompanying  nervus  cutaneus 


Fig.  7. — Course 
OF  THE  Veins 
IN  THE  Arm. 


90  LOCAL  ANESTHESIA 

antebrachii  must  be  kept  in  mind.  The  median 
vein  {yideY\g.  7)  is,  according  to  Bier,  not  well 
adapted  for  direct  anaesthesia,  especially  for 
operations  on  the  elbow-joint.  While  the  deeper 
parts  are  quite  insensitive,  there  is  always,  just 
peripheral  to  the  central  tourniquet,  a  cutaneous 
area  which  is  not  anaesthetic,  and  this  area  is 
larger  the  more  peripheral  the  site  of  injection 
(Figs.  8  and  9).  The  injection  must  there- 
fore be  made  as  close  up  as  possible  to  the 
central  tourniquet.  For  indirect  anaesthesia  (vide 
pp.  69,  72)  the  median  vein  is  quite  suitable. 

To  return  to  the  technique,  the  vein  having 
been  exposed  and  a  ligature  passed  round  it,  it  is 
drawn  u^)  by  means  of  the  ligature  into  the  upper 
angle  of  the  wound.  A  second  ligature,  peri- 
pheral to  the  first,  is  then  passed  round  the  vein, 
into  which  an  incision  is  made  with  a  fine  pair 
of  scissors  between  the  two  ligatures.  The 
needle  or  cannula  is  now  passed  carefully  into 
and  along  the  vein  in  a  peripheral  direction — 
injection  in  a  central  direction  has  occasionally 
been  followed  by  symptoms  of  poisoning — and 
the  peripheral  ligature  is  tied  round  the  vein  and 
cannula,  the  latter  being  then  withdrawn  until 
the  ligature,  which  is  drawn  somewhat  tight, 
slips  into  its  groove  (vide  p.  79  and  Fig.  4).  The 
ligature  is  then  securely  tied,  and  its  security 
tested  by  gently  drawing  the  cannula  backwards. 


GENERAL  TECHNIQUE  91 

The  0'5  per  cent,  solution  at  blood-heat  is  then 
injected  (maximum  quantity  100  c.c),  the  vein 
being  held  sightly  tense  during  the  injection. 
Many  patients  find   the    inflow  of  the    solution, 


Fig. 


Fig. 


Extent  of  Venous  Anjesthesia  according  to  Site  of 
Injection. 

which  causes  a  swelling  of  the  aflected  section  of 
limb  proportional  to  the  amount  injected,  some- 
what unpleasant. 

Bier  has  on  two  occasions  found,  when  operat- 


92  LOCAL  ANESTHESIA 

iiig  on  the  forearm,  that  the  valves  of  the  veins 
have  acted  as  an  obstruction.  In  both  cases  he 
was  able  finally,  by  the  exercise  of  considerable 
pressure,  to  overcome  the  resistance. 

After  the  injection  is  completed,  the  vein  is 
ligatured  above  and  the  small  wound  attended 
to  at  once. 

As  a  general  rule  direct  anesthesia  should  be 
employed  (vide  wfra).  According  to  Bier  80  c.c. 
of  solution  will  almost  always  be  found  sufficient. 


CHAPTER  Vir 

METHODS  FOR  ANESTHETIZING  THE  SKIN  AND 
THE  DIFFERENT  TISSUES  —  PROCEDURE  IN 
CERTAIN  DISEASED  CONDITIONS  — CIRCULAR 
ANALGESIA 

The  skin  is  an  organ  extraordinarily  sensitive  to 
pain,  the  most  sensitive,  in  fact,  of  the  whole  body. 
In  the  degree  of  this  cutaneous  sensibility  to  pain, 
however,  different  parts  of  the  body  differ  from 
each  other  very  widely.  The  least  sensitive  cuta- 
neous areas  are  probably  those  of  the  back  and 
the  abdomen,  the  most  sensitive  those  of  the  nose 
and  ear,  and  the  flexor  surface  of  the  fingers  and 
hands.  In  these  respects,  also,  however,  there  are 
wide  differences  between  individuals. 

The  skin  may  be  rendered  insensitive  either  by 
terminal  or  by  conduction  anaesthesia — that  is  to 
say,  by  anaesthetizing  either  the  sensory  "  end- 
organs"  in  the  skin,  or  the  terminal  sensory 
nerve-tracts  which  convey  sensory  impulses  from 
those  end-organs. 

In  the  first  method,  usually  given  Schleich's 
name  of  "  wheal  aniesthesia"  {Quctddelandsthesie), 

93 


94 


LOCAL  ANESTHESIA 


the  solution  is  injected  endermally  by  means  of  a 
fine  hollow  needle.  In  making  the  puncture  a 
fold  of  skin  should  be  pinched  up  where  this  is 

possible,  and  the  needle 
inserted  parallel  to  the 
cutaneous  surface.  A 
white  insensitive  wheal  is 
then  seen  to  form  immedi- 
ately after  the  solution  is 
injected.  The  needle  must 
be  kept  in  the  skin  itself, 
and  must  not  be  allowed 
to  pass  into  the  subcuta- 
neous cellular  tissue. 
Often,  if  the  skin  is  elastic 
and  not  too  thin,  the 
needle  may  be  pushed 
forward  endermally,  so  as 
to  anaesthetize  an  area  of 
skin  of  considerable  length. 
As  a  rule  one  must  be 
satisfied  with  making  as 
large  a  wheal  as  possible, 
and  then  making  another 
Fig.  10.— Wheal  Anesthesia   puncture   within  the  area, 

but  near  the  edge,  of  the 
first  wheal,  which  is  now  anaesthetic  {vide  Fig.  10). 
The  first  puncture  may  be  rendered  painless  by 
the  use   of  ethyl   chloride.     If,  however,   a    fine 


METHODS  FOR  ANAESTHETIZING  THE  SKIN    95 

needle  is  used,  the  pain  of  the  puncture  is  very 
slight.  A  0*25  per  cent,  novocain  solution,  with 
a  small  dose  of  suprarenin  added,  is  quite  sufficient 
for  longer  operations.  In  minor  operations  re- 
quiring stronger  (0*5  or  1  per  cent.)  solutions, 
however,  small  areas  of  skin  can  be  safely 
anaesthetized  with  these  solutions.  A  larger 
dosage  of  suprarenin  is  not,  in  my  opinion,  advis- 
able in  this  form  of  anaesthesia.  As  the  pressure- 
oedema  helps  to  intensify  the  anaesthesia,  small 
doses  of  suprarenin  (at  most  1  minim  to  each 
10  c.c.  of  solution)  are  sufficient  to  increase  the 
duration  and  intensity  of  the  anaesthesia  without 
risk  of  injury  to  the  tissues. 

The  area  infiltrated  in  the  above  manner  is  but 
a  narrow  one,  and  the  anaesthesia  does  not  extend 
much  beyond  the  borders  of  the  wheals  themselves  ; 
it  is  important,  therefore,  that  in  suturing  at  the 
end  of  the  operation  the  stitches  should  be  inserted 
within  the  zone  of  infiltration. 

Nowadays  the  skin  is  generally  anaesthetized 
by  conduction  anaesthesia  from  the  subcutaneous 
cellular  tissue.  This  does  not,  like  the  skin,  possess 
sensory  end-organs,  but  only  terminal  sensory 
nerve-tracts,  for  the  skin  or  organs  situated  imme- 
diately beneath  it  (glands),  and,  e.g.,  in  the  head, 
also  sensory  fibres,  which  penetrate  the  fasciae 
towards  the  deeper  parts  and  suppl}^  the  peri- 
osteum. 


96  LOCAL  ANESTHESIA 

In  this  method  the  subcutaneous  cellular  tissue 
is  infiltrated  from  two  opposite  points,  chosen  with 
reference  to  the  position  and  extent  of  the  area  to 
be  anaesthetized,  generally  with  0*5  or  1  per  cent, 
novocain  solution  and  suprarenin,  and  an  anaes- 
thesia of  the  overlying  skin  area  then  develops. 
The  rapidity  of  its  onset  is  dependent  on  various 
circumstances.  Thus  where,  as  in  the  scalp,  the 
injection  causes  a  bulging  outward  of  the  skin, 
anaesthesia  comes  on  quickly,  often  immediately. 
Where,  on  the  other  hand,  the  subcutaneous 
cellular  tissue  is  very  rich  in  fat,  as  in  the  gluteal 
region,  considerable  quantities  of  concentrated 
solutions,  large  additions  of  suprarenin,  and  a  long 
period  of  waiting,  are  often  required  before  a  con- 
dition of  anaesthesia  can  be  attained.  In  many 
operations  it  is  preferable  to  inject  the  subcuta- 
neous cellular  tissue,  not  underneath,  but  around 
the  line  of  incision,  so  that  the  surgeon  will  be 
able  afterwards  to  operate  in  tissues  in  a  normal 
condition. 

The  foregoing  rules  apply  also  to  the  anaestheti- 
zation  of  the  subcutaneous  cellular  tissue  itself. 

Anaesthesia  of  mucous  membranes  is  brought 
about  either  by  "painting"  the  mucous  surface 
with  the  anaesthetic  solution,  or  by  conduction 
anaesthesia,  as  just  described  in  the  case  of  the  skin. 
In  the  latter  case  the  first  incision  may  be  ren- 
dered painless  by  the  previous  application  of  10  per 


METHODS  FOR  ANESTHETIZING  THE  SKIN    97 

cent,  phenol  solution  (Schleich's),  or  of  10  per  cent, 
novocain  solution. 

It  is  important  not  to  employ  too  dilute  solu- 
tions. As  above  stated,  the  1  per  cent,  solution 
of  novocain  is  •  the  best  for  all  minor  operations. 
This  solution  very  soon  interrupts  conduction  of 
sensory  impulses,  even  in  the  larger  nerve-branches 
which  traverse  the  subcutaneous  cellular  tissue,  so 
that  prolonged  waiting  is  unnecessary. 

Let  us  take  a  concrete  example,  for  instance,  the 
excision  of  a  lupous  focus  in  the  face.  The  con- 
duction of  sensory  impulses  from  the  diseased  area 
is  to  be  thoroughly  interrupted  without  infiltrating 
the  area  itself.  In  the  first  place  the  subcutaneous 
cellular  tissue  in  the  neighbourhood  of  the  focus 
must  be  infiltrated  from  two,  or,  if  the  diseased 
area  be  a  large  one,  from  four,  injection  points  a 
few  centimetres  outside  the  operation  area,  with 
1  per  cent,  novocain  solution +  suprarenin.  This 
will  interrupt  the  conduction  of  sensory  impulses 
in  most  of  the  nerve  channels  supplying  the  area. 
It  is  a  good  plan  to  render  the  injection  points 
insensitive  by  the  method  of  "  wheal "  anaesthesia, 
so  that  the  subsequent  injection  with  a  larger 
needle  may  be  painless.  In  many  cases  the  injec- 
tions above  described  suffice.  Often,  however,  the 
affected  area  is  also  supplied  with  sensory  nerves 
which  reach  it  from  the  deeper  parts.  Besides 
this,  nerve-  trunks  often  traverse  the  subcutaneous 

7 


98  LOCAL  ANAESTHESIA 

cellular  tissues  for  considerable  distances,  and  these 
will  be  of  notable  calibre  at  the  points  of  injec- 
tion. In  order  to  interrupt  conduction  in  these 
also  it  is  necessary  to  infiltrate  the  subcutaneous 
cellular  tissue  immediately  underneath  as  well  as 
that  surrounding  the  diseased  focus.  We  have 
then  the  most  commonly  employed  form  of 
local  anaesthesia,  the  so-called  circular  analgesia 
of  Hackenbruck — i.e.,  the  disconnection  of  an 
area  of  operation  by  circular  interruption  of 
all  sensory  nerve-channels  supplying  the  area. 
The  method  is  applicable  to  the  great  majority 
of  diseased  conditions  necessitating  operations 
on  the  skin  or  subcutaneous  cellular  tissues, 
furuncles,  tumours,  foreign  bodies,  lymphadenitis, 
etc.  The  peripheral  parts  of  the  area  are  the 
first  to  become  anaesthetic,  the  nerves  supply- 
ing the  central  portions  being  ''caught,"  so  to 
speak,  by  the  anaesthetic  at  a  greater  distance 
from  their  terminations,  and  being,  therefore,  of 
larger  calibre  than  those  supplying  the  periphery. 
Diffusion  phenomena  also  play  a  part  in  the  matter, 
as  is  often  made  plain  by  the  spread  of  a  whitish 
tint  from  the  periphery  towards  the  centre. 

Difiiculties  may  arise  in  cases  where  nerves  of 
considerable  calibre  pass  direct  from  the  deeper 
tissues  to  the  diseased  organ.  Thus  it  is  often 
difficult  to  render  completely  painless  an  opera- 
tion for  the  extirpation  of  inflamed  inguinal  glands. 


METHODS  FOR  ANAESTHETIZING  THE  SKIN    99 

The  boundary  of  the  possible  area  of  circular  anal- 
gesia is  here  placed  where  the  inflamed  area  and 
the  underlying  tissues  join,  so  that  it  is  impossible 
to  inject  beneath  the  focus  and  thus  completely 
interrupt  the  sensory  conduction.  An  exception 
is  formed  where  subcutaneous  nerves  j^ass  through 
the  fascia  to  the  deeper  tissues  and  supply 
periosteum  and  bone — e.g.,  on  the  scalp.  Other- 
wise we  must  in  these  cases  either  ansesthetize 
the  larger  nerve-trunks  where  we  can  reach  them, 
or — as,  for  instance,  in  an  extirpation  of  inguinal 
glands,  where  the  mass  is  in  intimate  connection 
with  the  underlying  tissues — we  must,  after  sub- 
cutaneous injection,  proceed  to  infiltrate  succes- 
sively with  a  large  amount  of  anaesthetic  solution 
the  tissues  through  which  the  surgeon  will  have 
to  make  his  incisions.  Often,  when  it  is  not 
essential  to  render  insensitive  the  whole  diseased 
area — as,  for  instance,  in  a  parulis  which  is  "point- 
ing"— we  merely  infiltrate  by  Schleich's  method 
the  line  of  incision.  We  can  generally  do  this 
painlessly  in  spite  of  our  rule  against  infiltrating 
inflamed  tissues,  as  the  existing  oedema  has  lowered 
the  sensibility  of  the  parts,  and,  secondarily,  in- 
flamed skin  is  often  less  sensitive  than  that  attacked 
by  a  primary  inflammation.  No  wheal  is  formed 
in  this  case,  but  the  solution  diffuses  itself  through 
the  relaxed  tissues,  and  must  be  injected  in  con- 
siderable quantity.     Where,    then,    we    have   an 


100  LOCAL  ANESTHESIA 

area  of  oedematous  and  only  secondarily  affected 
skin  overlying  inflamed  parts,  it  is  often  possible 
to  infiltrate  those  parts  painlessly  without  previous 
injection  of  surrounding  sound  tissues.  The  matter 
is  still  more  simple  in  the  case  of  a  small  incision 
or  puncture  of  an  abscess,  if  the  skin  and  other 
covering  tissues  are  quite  sound.  It  is  only  neces- 
sary to  inject  continuously,  as  the  needle  is  passed 
on  through  the  overlying  tissues,  in  order  to 
render  the  whole  path  of  the  puncturing  instru- 
ment anaesthetic.  All  the  more  important  is  it, 
however,  in  inflammations  of  the  skin  itself,  such 
as  boils  and  carbuncles,  to  avoid  infiltrating 
inflamed  parts  until  they  have  been  rendered 
anaesthetic.  This  is  only  likely  to  present  diffi- 
culty when  the  inflammation  extends  into  the 
deeper-lying  parts,  as,  for  instance,  in  the  case  of 
a  large  cervical  carbuncle.  In  such  a  case  we 
must,  following  Schleich's  practice,  infiltrate  the 
tissues  step  by  step,  starting  in  sound  tissues,  and 
only  after  the  onset  of  anaesthesia  (which  is  quite 
rapid  if  1  per  cent,  novocain  solution  is  employed) 
continue  the  injection  till  the  whole  diseased  focus 
has  been  surrounded.  Otherwise,  when  several 
layers  of  tissue  have  to  be  infiltrated,  the  rule  of 
infiltrating  the  deeper  layers  first,  holds  good. 

The  foregoing  applies,  of  course,  also  to  super- 
ficial tumours.  Malignant  tumours,  however, 
should  not   be  operated  upon  under  local  anaes- 


METHODS  FOR  ANESTHETIZING  THE  SKIN   101 

thesia,  in  the  absence  of  a  clear  demarcation 
between  the  cancerous  and  the  healthy  tissues.  If 
the  cancerous  growth  has  attacked  the  surround- 
ing parts,  and  especially  if  the  neighbouring  glands 
are  involved,  operating  under  local  anaesthesia 
cannot  be  too  strongly  deprecated.  General  anaes- 
thesia is  here  avoided  at  a  heavy  cost,  radical 
removal  of  the  tumour  and  of  its  metastases  in 
the  neighbouring  glands  being  impossible  without 
it.  In  the  case  of  innocent  tumours  intimately 
attached  to  the  underlying  tissues  the  method 
above  described,  as  applicable  to  the  extirpation 
of  inguinal  glands,  may  be  recommended.  First 
free  injection  around  the  diseased  glands,  the  dis- 
secting out  being  continued  under  Schleich's  infil- 
tration method.  It  is  particularly  important  to 
secure  complete  anaesthesia  when  operating  for  the 
removal  of  foreign  bodies.  Every  surgeon  of 
experience  in  this  matter  knows  how  frequently 
unpleasant  surprises  are  experienced.  It  is  often 
necessary,  especially  when  the  foreign  body  is 
situated  deeply  in  the  substance  of  a  muscle,  to 
bring  Schleich's  infiltration  method  to  one's  aid. 

As  regards  other  tissues  of  the  body,  it  should 
be  noted  that  tendons  are  insensitive,  while  the 
tough,  connective  tissue  surrounding  them  and 
their  sheaths  has,  on  the  contrary,  a  high  degree 
of  sensibility  to  pain.  Muscle  fasciae,  or  apo- 
neuroses, are  also  in  most  parts  sensitive.     As  a 


102  LOCAL  ANESTHESIA 

rule,  therefore,  it  is  sufficient,  in  order  to  render 
tendons  and  fasciae  anaesthetic,  to  infiltrate  the 
surrounding  connective  tissue.  Local  anaesthesia 
is  not  suitable  for  operations  on  tendons  involved 
in  cicatricial  tissue,  unless  a  pure  conduction 
anaesthesia  can  be  employed. 

Muscles  behave  in  much  the  same  way  as  the 
subcutaneous  cellular  tissue.  Broadly  speaking, 
their  substance  is  insensitive  to  pain.  They  are, 
however,  traversed  in  many  parts  by  sensory 
nerves,  interference  with  which  causes  pain.  Small 
scars,  or  sclerosed  centres  in  muscle,  are  particu- 
larly sensitive.  Muscles  should  be  freely  infil- 
trated, and  usually,  following  Schleich's  practice, 
with  not  too  dilute  solutions.  Schleich  himself 
has  often  used  0*5  j)er  cent,  cocain  solutions.  It  is 
necessary  to  wait  a  few  minutes  for  the  full 
development  of  anaesthesia. 

Divergent  views  prevail  as  to  the  sensibility  of 
the  periosteum.  The  truth  of  the  matter  would 
appear  to  be  that  in  some  regions  the  periosteum 
has  no  sensibility,  while  in  others  it  is,  on  the 
contrary,  extraordinarily  sensitive  to  pain. 

The  bones  are  as  a  rule  supplied  with  sensory 
nerves  from  the  periosteum.  If  the  periosteum 
be  elevated  from  the  bone,  the  outer  uncovered 
surface  of  the  latter  is  insensitive.  The  medulla  of 
bone,  however,  exhibits,  according  to  Schleich,  sensi- 
bility to  pain.   Thus  it  has  been  repeatedly  observed 


METHODS  FOE  ANESTHETIZING  THE  SKIN   103 

that  in  amputations  carried  out  under  local  anses- 
thesia  the  whole  operation  is  painless,  except  the 
sawing  through  of  the  bone.  This  is  probably  to 
be  explained  by  the  fact  that  nerves  traverse  the 
substance  of  bones  for  considerable  distances,  and 
as  the  periosteum  is,  in  practice,  only  elevated  for  a 
short  distance,  the  medulla,  at  the  given  point,  con- 
tains sensory  nerves,  which  have  passed  from  the 
periosteum  to  the  bone  at  points  central  to  the  line 
of  amputation.  Ansesthetization  of  bone  and  perios- 
teum is  brought  about  with  the  most  facility  where 
we  are  able  to  induce  anaesthesia  by  interruption 
of  conduction  in  superficially  situated  nerve-trunks, 
as,  for  instance,  in  the  fingers,  the  scalp,  or  the 
lower  jaw  {nervus  alveolaris  inferior).  In  flat 
bones  injections  must  be  made  around  the  affected 
area  at  as  deep  a  level  as  possible  {e.g.,  focus  in 
sternum).  Finally,  in  the  case  of  many  hollow 
bones — as,  for  instance,  in  resection  of  ribs — we 
must  inject  all  round  the  whole  area  of  bone 
which  we  wish  to  anaesthetize.  If  this  is  done 
thoroughly,  it  is  sufficient  if  the  needle  be  passed 
down  close  to  the  periosteum,  and  it  is  not  neces- 
sary to  proceed  to  an  actual  subperiosteal  infiltra- 
tion. As  stated  above,  the  deeper  layers  are 
always  injected  first,  and  then  the  subcutaneous 
tissues. 

For  cartilage  and  perichondrium  the  same  rules 
apply  as  for  bone  and  periosteum,  both  as  regards 


104  LOCAL  ANESTHESIA 

sensibility  to  pain  and  the  best  methods  of  pro- 
ducing ansesthesia. 

As  regards  articular  capsules,  ligaments,  and 
synovial  membranes,  though  the  opposite  opinion 
has  been  expressed,  Braun's  view  is  undoubtedly 
correct,  that  these  possess  a  somewhat  high  degree 
of  sensibility,  which,  as  is  the  case  also  with  all 
the  tissues  we  have  considered,  is  very  much 
increased  in  inflammatory  conditions.  In  major 
operations  on  the  larger  articulations,  as  also  in 
many  operations  on  the  large  tubular  bones  of  the 
extremities,  venous  anaesthesia  is  likely  soon  to 
displace  other  methods.  In  simple  puncture  of  a 
joint  the  same  procedure  is  adopted  as  for  the 
puncture  of  abscesses.  If  an  irritant  substance 
has  to  be  injected  into  a  joint,  the  latter  is  first 
freely  injected  with  0*5  per  cent,  novocain  solution 
+  suprarenin.  After  the  lapse  of  a  period  of  five 
to  ten  minutes  the  joint  is  entirely  insensitive. 
The  ansesthesia  can  be  tested  by  moving  the  trocar, 
which  has  been  left  in  situ,  backwards  and  for- 
wards, and  when  found  to  be  complete  the 
medicament  should  be  injected  at  once. 


CHAPTER  VIII 

OPEEA.TIONS  ON  THE  HEAD 
1.  Operations  on  the  Scalp  and    Forehead. 

As  already  stated,  the  scalp  is  a  specially  favour- 
able region  for  the  application  of  local  anaesthesia, 
inasmuch  as  the  nerves,  running  for  considerable 
distances  under  and  parallel  to  the  skin,  ultimately, 
after  passing  through  the  fascia  to  the  deeper 
tissues,  innervate  the  bones  of  the  skull  and  their 
periosteum,  so  that  it  is  easier  here  than  in  most 
other  regions  of  the  body  to  bring  about  an  anaes- 
thesia of  bone  by  subcutaneous  injections.  The 
usually  small  development  of  fat  in  this  region  is 
also  favourable  to  the  attainment  of  an  anaesthesia 
on  which  one  can  rely. 

A  glance  at  Fig.  11  shows  the  course  of  the 
nerves,  and  makes  it  clear  that  near  the  points  of 
exit  of  the  nerves  it  is  possible,  without  circular 
injection,  and  merely  by  subcutaneous  injection  of 
a  strip  at  right  angles  to  the  course  of  the  nerve, 
to  bring  about  anaesthesia  of  a  given  area.  This 
carmot,  however,  be  recommended   as   a  general 

105 


106 


LOCAL  ANESTHESIA 


practice,  in  view  of  the  existence  of  occasional 
irregularities  in  the  course  of  the  nerves.  The 
method  is  most  to  be  depended  on  when  applied 
to  the  frontal  region.  In  general,  however, 
circular    injection    alone    gives    certainty    of   the 


Fig.  11. — Course  of  the  Sensory  Nerves  of  the  Face  (Braun). 

1,  N.  frontalis ;  2,  N".  supraorbitalis ;  3,  N.  zygomat.  temporalis 
(Trigem.  II.)  ;  4,  N.  auriculo-temporalis  (Trigem.  III.)  ;  5,  N.  auricu- 
laris  magnus ;  6,  K.  occipitalis  minor;  7,  N.  occipitalis  major; 
8,  N.  supra-  and  infra-trochlearis  ;  9,  N.  infraorbital  is  ;  10,  R.  nasalis 
ext.  N.  ethmoidalis ;  11,  N.  mentalis. 

attainment  of  a  complete  anaesthesia.     It  is,  how 
ever,  not  as  a  rule  necessary  on  the  scalp  or  fore- 
head— in  view  of  the  general  course  and  distribu- 
tion of   the  nerves  above  described — to  pass  the 
injecting    needle    beneath    the    affected    area,    it 


OPERATIONS  ON  THE  HEAD  107 

being  generally  sufBcient  to  make  one's  injections 
around  the  area  of  operation   in   the   form   of  a 
circle  or  rhombus.     The  necessary  first  treatment 
of  head  injuries,  even  of  those  involving   severe 
injury  to    bone,  can   be    carried    out    under    this 
method  most  satisfactorily.     The  parts  surround- 
ing the  injury  are  dry- shaved,  the  skin  near  the 
wound    is    painted    with  tincture   of  iodine,   the 
anaesthetic    solution  is  injected,  and  the  area  of 
operation  is  then  further  prepared  by  cleansing 
with  ether  or  benzine.     If  the  dura  mater  is  met 
with  in  the  course  of  the  operation,  no  harm  is 
done,    as    the    injections   will    have    rendered    it 
insensitive    by    interrupting    conduction    in    its 
sensory  nerves.     My  experience  in  a  good  many 
operations  entirely  bears  out  Braun's  statements  in 
this  regard.      Cases  have  been  recorded,  however, 
by  other  observers  in  which  the  dura  retained  its 
sensibility.     The  surface   of  the  brain,   however, 
seems   to  be    quite    insensitive,    the  fact    having 
been  established  by  numerous  recorded  observa- 
tions on  the  living  subject.    Trephining  operations, 
therefore,    especially   where    there    is    no    large 
amount  of  muscular  tissue  beneath  the  galea,  are 
specially  suitable    for   local    anaesthesia.     Supra- 
renin  is  here  of  great  utility.     In  the  proportion 
of  1   minim  of  synthetic  suprarenin  to  10  c.c.  of 
solution  it  causes  a  sufficient  degree  of  ansemJa, 
and  renders  superfluous  Heidenhain's  method  of 


108  LOCAL  ANESTHESIA 

ligation.  Where,  in  view  of  the  large  area  of  the 
field  of  operation,  very  large  quantities  of  solution 
have  to  be  employed,  the  suprarenin  may  be  given 
in  still  more  dilute  proportion.  It  has  also  been 
recommended  in  operations  under  general  anaes- 
thesia that,  instead  of  ligation,  a  dilute  suprarenin 
solution  should  be  injected  with  a  view  to  the 
prevention  of  haemorrhage.  I  have  obtained  a 
thoroughly  satisfactory  local  anaemia  after  injec- 
tion of  1  minim  of  suprarenin  to  20  c.c.  of  solution. 
Heidenhain's  method,  however,  must  be  regarded 
as  that  which  involves  least  risk  of  doing  harm. 
To  what  extent  local  anaesthesia  will  secure  adop- 
tion in  larger  operations  on  the  skull  the  future 
alone  can  decide.  It  is,  however,  not  everyone 
who  can  bring  himself  to  let  his  skull  be  chiselled 
open  while  he  is  fully  conscious.  One  of  my 
patients  told  me  that,  though  he  suffered  no  pain, 
the  sensations  of  hammering  and  boring  were  so 
horrible  that  he  would  much  prefer  to  be  put 
under  chloroform.  Such  points  must  be  borne  in 
mind,  in  the  absence  of  some  very  compelling 
ground  for  avoiding  general  anaesthesia,  and  the 
boon  of  unconsciousness  should  not  be  denied  such 
patients. 

The  foregoing  applies  only  to  those  parts  of  the 
head  in  which  the  periosteum  lies  immediately 
under  the  galea,  so  that  other  tissues  are  not  in 
question.    If  the  operation  is  to  be  performed  on  a 


OPERATIONS  ON  THE  HEAD  109 

region  nearer  the  face,  a  careful  circular  injection 
must  be  carried  out.  Where  muscles  are  situated 
between  the  skin  and  the  bone  {e.g.^  maxilla 
temporalis),  these  also  must  be  carefully  infiltrated. 
If  two  dilute  solutions  are  not  employed,  which  is 
seldom  necessary  here,  where  large  quantities  of 
solution  are  hardly  ever  required,  a  reliable 
anaesthesia  can  be  attained  in  any  part  w^ithout 
paying  too  close  attention  to  the  exact  points  of 
exit  of  the  superficial  nerves. 

In  trephining  the  frontal  sinus,  injections  are 
made,  first  deeply  and  then  subcutaneously,  around 
the  point  where  the  trephine  is  to  be  applied. 
The  trephining  can  readily  be  made  painless. 
The  mucous  membrane  of  the  sinus,  however,  is 
supplied  by  the  ethmoidal  nerve,  which  passes 
from  the  orbit.  As  an  interruption  of  conduction 
in  this  nerve  is  hardly  practicable,  necessary 
manipulations  of  the  mucous  membrane  must  be 
rendered  painless  by  the  application  to  it  of  a 
concentrated  solution  — 10  per  cent,  novocain 
solution  +  suprarenin.  The  method  is  not  very 
satisfactory,  and  where  it  is  necessary  to  go 
beyond  the  mucous  membrane  the  case  is  quite 
unsuitable  for  local  anaesthesia. 


no  LOCAL  ANAESTHESIA 

2.   Operations  on  the  Face. 

The  rules  already  laid  down  for  anaesthetizing 
the  skin  and  subcutaneous  cellular  tissue  will  as 
a  rule  be  found  sufficient  in  the  case  of  operations 
on  the  soft  parts  of  the  face,  such  as  incisions  of 
furuncles,  removal  of  tumours,  plastic  operations, 
etc.  If  1  per  cent,  novocain  solution  is  employed, 
it  is  hardly  necessary  to  pay  minute  attention  to 
the  points  of  exit  of  the  nerves  through  the 
fascia,  though,  should  such  a  point  come  within 
the  area  of  operation,  a  somewhat  more  copious 
infiltration  may  be  made  in  its  neighbourhood. 
Large  quantities  of  solution  are  not  generally 
required,  so  a  few  extra  cubic  centimetres  may  be 
used  in  this  manner  without  misgiving.  The  dose  of 
suprarenin  need  not  be  large  for  operations  in  this 
region.  From  1  to  2  minims  of  synthetic  supra- 
renin to  each  10  c.c.  of  solution,  according  to  the 
amount  of  fat  in  the  subcutaneous  cellular  tissue, 
is  generally  sufficient.  In  a  large  number  of 
operations  injection  around  and  underneath  the 
affected  area  will  suffice.  Of  the  treatment  suit- 
able in  extensive  superficial  morbid  processes,  a 
concrete  example  has  been  given  above  in  the 
description  of  the  methods  to  be  applied  in  a  case 
of  lupus  of  the  cheek.  Should  the  focus  be 
attached  to  the  subjacent  tissus — e.g.,  should  it  be 
adherent  to  the  surface  of  the  superior  or  inferior 


OPERA.TIONS  ON  THE  HEAD  111 

maxilla — the  circular  injection  of  the  subcutaneous 
tissue  must  be  preceded  by  a  similar  injection  of 
the  deeper  layers  immediately  above  the  perios- 
teum. Here,  however,  should  the  area  of  opera- 
tion include  a  point  of  exit  of  one  of  the  nerves, 
it  will  be  necessary,  after  the  incision  of  the  skin, 
to  inject  a  small  quantity  of  solution  into  the 
larger  divisions  of  the  nerve. 

In  operations  on  the  eyelids  it  is  sufficient,  in 
the  case  of  either  eyelid,  to  infiltrate  along  the  line 
of  the  corresponding  bony  border  of  the  orbit. 

3.  Operations  on  the  Eae.^ 

With  regard  to  the  distribution  of  sensory  nerves 
to  the  ear,  the  following  points  should  be  borne  in 
mind  : 

The  pinna  and  external  auditory  meatus  are 
supplied — 

1.  By  the  auriculo-temporal  nerve. 

2.  By  the  auricular  branch  of  the  vagus. 

3.  By  the  great  auricular  nerve. 

The   nerves,  for   the   most   part,   pass   to    the 

meatus  from  in  front  and  from  below  (vide  Fig.  11). 

In  operations  on  the  pinna  it  is  generally  suffi- 

*  Privat-docent,  Dr.  Haike  kindly  assisted  me  in  the  pre- 
paration of  this  section,  as  also  of  that  dealing  with  operations 
on  the  nasal  and  oral  cavities. 


112  LOCAL  ANAESTHESIA 

cient  to  interrupt,  by  a  subcutaneous  infiltration, 
the  conduction  of  sensory  impulses  from  the  part 
to  be  dealt  with.  Very  small  quantities  of  solu- 
tion suffice  here,  as  the  skin  rises  immediately  in  a 
wheal -like  manner  after  even  a  small  injection. 

If  the  whole  pinna  is  to  be  anaesthetized,  all  that 
is  necessary  is  to  infiltrate  subcutaneously  in  a 
circle  immediately  around  it  with  1  per  cent, 
novocain-suprarenin  solution.  As  a  final  pre- 
caution, it  is  advisable  to  inject  deeply  an  extra 
2  or  3  c.c.  where  the  larger  branches  pass  to  the 
ear — that  is  to  say,  behind  the  lobe  of  the  ear  and 
in  front  of  the  mastoid  process. 

For  operations  on  the  external  auditory  meatus 
reliance  is  often  placed  on  the  application  of  a 
plug  of  cotton- wool  saturated  with  a  solution 
containing — 

Parts. 
Ac.  carboL  liq.  ...  ...         ...       5 

Cocainae  hydrochlor.    ...  ...  ...       2 

Menthol  2 

8p.  vini.  Teat.  ...         ...         ...         ...     10 

The  most  frequently  required  operation  in  this 
region — the  incision  of  boils— is  certainly  rendered 
less  painful  by  this  application,  but  is  by  no  means 
painless.  For  operation  on  the  bony  walls  of  the 
meatus  the  method  is,  of  course,  quite  useless.  The 
method  advocated  by  Eichen  and  Braun  for  opera- 
tions on  the  meatus  will  probably  gradually  secure 


OPERATIONS  ON  THE  HEAD  113 

wider  adoption.  Its  aim  is  to  amvsthetize,  by 
interruption  of  conduction,  the  nerves  above  de- 
scribed as  supplving  the  external  meatus. 

Solution  of  novocain  (1  per  cent.) +  su}U'arenin 
is  first  freely  injected  behind  the  lobe  of  the  ear 
in  the  depression  in  front  of  the  mastoid  j^rocess, 
the  needle  being  passed  deeply  in  along  the  lower 
border  oi'  the  auditory  meatus  ;  a  second  injection 
is  made  in  a  rather  more  anterior  position,  and  the 
neighbourhood  of  the  anterior  wall  of  the  meatus 
is  thus  intiltrated  with  the  same  solution.  After 
live  minutes  the  anaesthesia  is  as  a  rule  com- 
plete. 

Ditiiculties  occasionally  arise,  as,  for  instance,  in 
furuncles,  when  the  intlammation  has  spread  pos- 
teriorly to  the  adjacent  parts.  In  view  of  the 
extreme  sensitiveness  of  the  parts,  it  is  necessarv 
to  proceed  slowly  from  tiie  healthy  to  the  diseased, 
injecting  gradually  more  and  more  deeply. 

The  membrana  tympani  is  partly  supplied  by 
the  nerves  above  mentioned  ;  in  part,  however,  as 
is  also  the  case  with  the  middle  ear,  it  is  su[>plied 
by  sensory  fibres  from  the  glosso- pharyngeal  and 
vagus  nerves,  in  whose  case,  of  course,  an  inter- 
ruption of  conduction  is  out  of  the  question. 

By  instillation  of  the  above-n\entioned  phenol- 
cocain  solution  the  sensibility  of  tlie  membrana 
tympani  can  be  considerably  diniinished.  A  \Aed- 
li'et  oi'  cotton-wool  soaked  in   the  sohition  shouKl 


114  LOCAL  A^^STHESIA 

also  be  pressed  against  the  point  involved  until 
the  latter  becomes  whitish.  The  carbolic  acid 
renders  the  epidermis  more  permeable  by  the 
anaesthetic  solution.  As,  however,  the  solutions 
diffuse  only  very  imperfectly  through  the  epithe- 
lium of  the  membrana,  the  results  are  not  alto- 
gether satisfactory. 

Two  methods  have  been  introduced  recently  : 

Tiefenthal  takes  4  minims  of  20  per  cent,  cocain 
solution  +  1  minim  of  suprarenin,  allows  this 
quantity  to  act  upon  the  membrana  tympani 
for  fifteen  minutes,  and  then  injects  2  to  4  minims 
of  cocain-adrenalin  solution  (5  to  10  per  cent.) 
through  the  drum  at  its  lower  part  into  the  middle 
ear. 

Rupprecht  kneads  a  piece  of  alypin  about  the 
size  of  a  bean  with  2  minims  of  sujorarenin,  covers 
the  upper  half  of  the  drum  with  the  mixture,  and 
leaves  it  to  act  for  fifteen  or  twenty  minutes. 
According  to  E;upprecht,  the  osmotic  difference 
between  the  mixture  in  contact  with  the  drum 
and  the  lymph  of  the  middle  ear  facilitates  diffusion 
through  the  somewhat  impermeable  tympanic 
epithelium. 

Both  authors,  however,  admit  that  their  methods 
do  not  give  a  thoroughly  trustworthy  anaesthesia. 

It  must  be  remembered  that  often,  when  the 
ear-drum  is  near  the  ]3oint  of  j)erforation,  the 
amount  of  pain  caused  by  attacking  it  is  minimal : 


OPERATIONS  ON  THE  HEAD  115 

this  may  perhaps  explain  the  wide  differences  in 
the  recorded  results. 

Strenuous  attempts  have  been  made  to  arrive  at 
more  satisfactory  results  by  other  methods. 

Neumann,  in  particular,  has  pointed  out  new 
lines  on  which  to  attempt  the  ansesthetization  of 
the  membrana  tympani  and  of  the  organs  of  the 
middle  ear. 

Otologists  are  not  in  agreement  as  to  the  value 
of  these  methods  :  they,  however,  certainly  point 
out  a  way  by  which  we  can  bring  about  a  very 
thorough  deadening  of  sensibility  of  the  interior  of 
the  middle  ear. 

Neumann  discovered  that  an  anaesthetic  injected 
into  the  upper  wall  of  the  auditory  meatus  in  such 
a  manner  as  to  raise  it  from  its  bed  finds  its  way 
between  the  two  layers  of  the  membrana  tympani, 
and  thus  brin^-s  about  ansesthesia  of  the  drum  and 
of  the  middle  ear  (Fig.  12). 

A  2  2^er  cent,  novocain  solution  is  employed  with 
3  minims  of  added  suprarenin  to  each  5  c.c.  of 
solution.  The  heating  of  the  solution  to  45°  C, 
which  Neumann  recommends,  is  not  necessary. 
The  needle  is  inserted  from  ^  to  1  centimetre  in 
front  of  the  junction  between  the  cartilaginous 
and  the  bony  portions  of  the  meatus.  The  line  of 
junction  can  be  recognized  by  a  fold  formed  when 
the  pinna  is  raised  or  lowered,  also  by  the  glisten- 
ing of  the   bony  portion.     The  needle  is  passed 


116 


LOCAL  ANESTHESIA 


upwards  and  inwards  in  a  slanting  direction,  thus 
between  the  bone  and  the  upper  cutaneous  wall  of 
the  meatus.  The  anaesthesia  is  fully  established  in 
about  ten  minutes.  That  of  the  drum  is  complete, 
that  of  the  middle  ear-organs,  though  not  quite 
complete,  is  nearly  so. 

For    operations    on    the    membrana    tympani, 


Fig.  12. — Anesthetization  of  the  Membrana  Tympani  and 
Middle  Ear  (Neumann). 

especially  paracentesis,  the  method  has  not 
gained  wide  adoption,  as  there  is  a  general 
agreement  that  the  pain  of  the  injection  is  no 
less  severe  than  that  of  the  paracentesis  itself. 

On    the  other  hand,  the  method,  though  per- 
haps   not  yet    fully    perfected,    appears  to   point 


OPERATIONS  ON  THE  HEAD  117 

to  the  right  way  in  which  to  bring  about  ana-^s- 
thesia  for  operative  procedures  on  the  middle 
ear,  which  often  require  considerable  time  to 
carry  out.  Where  the  tympanic  cavity  is  to 
be  attacked  by  way  of  the  auditory  meatus  the 
method  is  as  a  rule  sufficient  in  itself. 

If  a  trephining  of  the  mastoid  process  is  to 
be  combined  with  the  "  radical  "  operation,  the 
method  must  be  reinforced  by  the  simple  and 
sure  method  of  anaesthetization  of  the  bone  from 
without. 

The  mode  of  procedure  follows  from  what  has 
been  said  above.  It  is  only  necessary  to  sur- 
round the  mastoid  process  with  a  deej),  and  a 
superficial  infiltration  with  1  j)er  cent,  novocain- 
suprarenin  solution,  and  the  bone  can  be  tre- 
phined painlessly  in  from  ten  to  fifteen  minutes. 
The  deep  infiltration  should  be,  as  far  as  possible, 
subperiosteal.  The  above- described  method  of 
anaesthetizing  by  way  of  the  meatus  then  comes 
into  use  for  the  deeper  parts.  The  performance 
of  this  operation  under  Schleich's  anaesthesia 
alone — that  is,  after  a  gradually  progressive 
infiltration  carried  deep  into  the  bone,  as  has 
been  practised  by  some  surgeons — has,  in  my 
opinion,  this  serious  drawback — viz,,  that  in  a 
region  so  rich  in  lymph  channels  infectious 
material  may  very  readily  be  carried  l)y  the 
infiltration  to  the  deeper  parts. 


118  LOCAL  ANESTHESIA 

In  operations  on  the  peripheral  portions  of  the 
nose  we  can  either  employ  a  circular  infiltration, 
for  which,  owing  to  the  tenseness  of  the  tissues, 
only  small  quantities  of  solution  are  required, 
with  little  or  no  added  suprarenin.  For  the 
removal  of  small  tumours  this  is  the  most  prac- 
tical method.  For  plastic  operations,  where  the 
area  of  operation  is  to  be  treated  as  gently  as 
possible,  conduction  anaesthesia  is  to  be  preferred. 
It  must  be  borne  in  mind  that  the  nasal  branch 
of  the  ethnoidal  nerve  issues  at  the  junction 
between  the  bony  cartilaginous  portions  of  the 
nose,  also  that  the  alae  nasi  and  the  septum 
receive  sensory  twigs  from  the  upper  lip.  In 
order  to  anaesthetize  the  whole  lower  end  of  the 
nose,  its  lower  border  must  be  infiltrated  first 
deeply,  then  subcutaneously,  the  upper  lip  being 
elevated  for  the  latter  infiltration ;  afterwards, 
starting  from  the  ridge  of  the  nose,  injections 
are  made  outwards  and  downwards,  in  a  slanting 
direction,  until  the  former  injection  points  are 
met  with.  The  deeper  parts  also  (cartilage) 
are  thus  rendered  anaesthetic.  If  it  is  desired 
to  anaesthetize  the  whole  organ,  the  second  infil- 
tration must  be  carried  out  from  the  root  of  the 
nose  along  its  lateral  borders,  and  it  will  be 
necessary,  in  view  of  the  nasal  branch  of  the 
ethnoidal  nerve,  to  inject  specially  a  narrow  strip 
at  the  junction  of  bone  and  cartilage  (Braun). 


OPERATIONS  ON  THE  HEAD  119 

Operations  ox  the  Nasal  and  Buccal 
Cavities. 

I  have  already  stated  that  for  producing  anaes- 
thesia of  mucous  membranes  cocahi  has  not  yet 
been  altogether  ousted  by  other  anaesthetics.  In 
two  respects,  indeed,  its  replacement  by  other 
substances  is  not  so  urgently  called  for  here  as  in 
the  method  of  anaesthesia  by  infiltration.  In  the 
first  place,  the  question  of  sterilization  is  here  of 
subordinate  importance,  while,  in  the  second,  it 
is  less  necessary  here  to  insist  on  entire  freedom 
from  tissue-irritant  qualities  in  the  drug  employed 
than  is  the  case  with  subcutaneous  injections. 
There  remains,  however,  the  risk  of  poisoning, 
which,  in  sj)ite  of  improvement  since  the  intro- 
duction of  suprarenin,  is,  in  my  opinion,  a  some- 
what serious  one,  though  cases  of  severe  poisoning 
are  but  rare.  Those  who  still,  at  the  present 
day,  employ  cocain  for  anaesthetizing  mucous 
membrane,  give  as  their  reason  that  for  this 
particular  purpose  none  of  the  newer  preparations 
equal  cocain  in  respect  of  the  completeness  of  the 
anaesthesia  produced.  A  number  of  other  authors, 
however,  state,  in  opposition  to  this  view,  that 
here  also  they  have  had  excellent  results  with 
the  newer  anaesthetics,  particularly  with  novocain 
and  alypin. 

Both  of  these  are  used,  like  cocain,  in  10  to  20 


120  LOCAL  ANESTHESIA 

per  cent,  solution.  The  dose  of  suprarenin  must  be 
fairly  strong,  about  5  minims  per  cubic  centimetre. "^^ 
The  application  is  made  with  a  brush  (pharynx),  or 
by  placing  in  situ  pledgets  of  cotton-wool  soaked 
in  the  solution  and  changing  them  frequently. 
Care  must  be  taken  that  none  of  the  solution 
passes  down  the  oesophagus,  and  to  this  end  too 
free  a  soaking  of  the  cotton-wool  should  be 
avoided.  The  shrinkage  of  mucous  membrane 
caused  by  the  action  of  suprarenin  is  in  many 
cases  of  great  importance  as  an  aid  both  to 
diagnosis  and  to  the  carrying  out  of  operative 
procedures. 

The  anaesthesia  brought  about  in  this  manner 
is  limited  to  the  mucous  membrane.  If  operations 
on  bone  are  to  be  undertaken  (septum  resections, 
etc.),  infiltration  must  take  the  place  of  external 
applications.  In  septum  resections  the  surgeon 
injects  on  both  sides  of  the  septum  beneath  its 
covering  mucous  membrane  with  1  per  cent, 
novocain  solution  with  a  small  addition  of  supra- 
renin, and  proceeds  gradually  from  before  back- 
wards. 

Attempts  have  quite  recently  been  made 
{Rujjpreclit)  to  devise  a  satisfactory  local  anaes- 
thetic technique  for  two  minor  operations  of  great 

*  Haike  has  several  times  observed,  after  the  use  of  supra- 
renal preparations,  a  nasal  discharge,  very  troublesome  to  the 
patient,  and  lasting  several  days. 


OPERATIONS  ON  THE  HEAD  121 

importance  to  the  practical  surgeon  —  for  the 
extirpation  of  tonsils  and  the  removal  of  adenoid 
vegetations. 

Many  surgeons  deny  the  necessity  of  any  local 
anaesthesia  for  these  two  operations,  and  object, 
on  account  of  the  expenditure  of  time,  to  a  prepa- 
ration for  operation  whose  duration  seems  out  of  all 
proportion  to  the  short  time  necessary  for  the  actual 
operative  procedure.  At  the  same  time,  the  efforts 
being  made  in  the  matter  deserve  attention.  If 
the  public  should  come  to  realize  that  it  is  pos- 
sible to  perform  these  operations  painlessly,  under 
local  anaesthesia,  many  patients  will  certainly 
express  a  wish  that  it  shall  be  done  in  their  case. 
At  present,  however,  the  methods  are  by  no  means 
perfected,  for  "  painful  "or  ''  slightly  painful  "  are 
words  still  frequently  occurring  in  reports  of  cases. 
Many  patients,  too,  and  especially  young  children, 
are  unsuitable  subjects  for  any  method  of  the  kind. 

In  the  operation  for  the  removal  of  adenoid 
vegetations  it  is  of  the  first  importance  to  anaes- 
thetize thoroughly  the  very  sensitive  appendage 
to  the  choana.  In  particularly  sensitive  patients, 
with  a  view  to  rendering  the  mirror  examination 
also  painless,  about  1  c.c.  of  cocain-suprarenin 
solution  should  be  first  cautiously  applied  to  the 
interior  of  the  nose  as  a  spray.  After  waiting 
from  eight  to  fifteen  minutes  from  the  onset  of 
anarjsthesia    pledgets    of    cotton -wool    soaked    in 


122  LOCAL  ANESTHESIA 

10  per  cent,  alypin-suprarenin  solution  are  intro- 
duced by  means  of  sounds  or  applicators  into 
the  nostrils,  while  the  patient  lies  down  with  head 
thrown  back.  A  sound  is  left  for  a  time  in  each 
nostril  with  its  pledget  in  contact  with  the 
appendage  to  the  choana.  After  a  few  minutes 
the  sounds  are  changed  for  fresh  ones,  the  process 
being  repeated  three  or  four  times,  so  that  the 
whole  procedure  lasts  about  ten  or  twelve  minutes. 
The  surgeon  waits  a  few  minutes,  and  then  carries 
out  his  operative  procedures  within  the  ensuing 
ten  minutes. 

In  operations  on  the  tonsils  the  method  applied 
is  particularly  suitable  for  the  recently  practised 
total  enucleation  of  those  organs.  It  consists  in 
injecting  (with  a  Record  syringe,  carrying  a  special 
attachment)  2  per  cent,  novocain  solution  into  the 
tonsils,  after  Schleich's  method.  Before  the  injec- 
tion the  tonsils  may  be  painted  with  10  per  cent, 
alypin  solution.  The  solution  is  injected  into  the 
tonsil  around,  and  as  near  as  possible  to,  its  base. 
Sj3ecial  importance  is  to  be  attached  to  the  due 
infiltration  of  the  upper  pole  of  the  tonsil  (exit  of 
nerve) ;  the  infiltration  of  the  lower  pole  also  is 
advisable,  with  a  view  to  the  prevention  of 
haemorrhage. 

After  the  infiltration  it  is  necessary  to  wait 
eight  or  ten  minutes. 

In    operations     on    the    lachrymal    sac     it    is 


OPEEATIONS  ON  THE  HEAD  123 

advisable  to  inject  around  the  whole  area  of 
operation  ;  it  is  generally  sufficient,  in  addition, 
to  inject  at  the  inner  canthus  (N.  intratroch- 
learis)  ;  this  cannot,  however,  always  be  fully 
relied  on,  as  sensory  branches  often  reach  this 
region  from  a  mesial  direction. 

Operations  on  the  Eye.* 

While,  as  we  have  seen,  the  ansesthetization  of 
mucous  membranes  by  external  application  pre- 
sents certain  difficulties,  the  ocular  conjunctiva  is 
an  exceedingly  favourable  field  for  the  employ- 
ment of  local  anaesthesia.  Apart  from  the  pro- 
perty possessed  by  the  conjunctiva  of  readily 
taking  up  watery  fluids  by  diffusion,  we  can 
secure  here  a  more  prolonged  action  of  the  drug 
than  we  can  with  mucous  membranes,  by  the 
simple  plan  of  holding  the  lower  lid  a  little  away 
from  the  eye  and  making  the  patient  look  down- 
wards, so  that  the  eye  is  bathed  in  the  solution, 
filling  the  lower  conjunctival  sac.  As  a  con- 
sequence we  can  secure  satisfactory  results  with 
far  less  concentrated  solutions  of  the  anaesthetic 
drug  ;  this  is  desirable  also,  because  too  concen- 
trated solutions  might  easily  be  harmful  to  the 
corneal  epithelium.     The  majority  of  ophthalmolo- 

■■'-  My  thanks  are  due  to  Dr.   Fehr  for  assistance  in  the 
preparation  of  this  section. 


124  LOCAL  ANESTHESIA 

gists  have  remained  faithful  to  cocain,  though 
recently  a  number  have  also  employed  holocain, 
alypin,  tropacocain,  and  novocain.  For  subcu- 
taneous and  subconjunctival  injection  tropacocain 
must  be  entirely  rejected,  on  account  of  its  power- 
fully irritant  effects  ;  novocain  takes  first  place, 
and  the  otherwise  almost  abandoned  eucain  also 
renders  good  service. 

Alypin,  in  contrast  to  cocain,  causes  vaso-dila- 
tation,  and  in  many  cases  gives  rise  to  a  condition 
of  general  irritability  which  is  unpleasant  to  the 
patient. 

With  reference  to  one  important  question,  that 
of  injury  to  the  corneal  epithelium,  there  is,  at 
present,  no  general  agreement  of  authorities. 
Many  regard  alyjDin  as  in  this  respect  the  most 
satisfactory  anaesthetic  ;  others,  on  the  contrary, 
maintain  that  with  the  usual  precautions  (covering 
the  eye),  and  in  solutions  of  the  usual  strength, 
cocain  is  the  least  harmful  drug.  The  principal 
ground  on  which  cocain  has  been,  in  other  direc- 
tions abandoned — its  toxicity — hardly  comes  into 
consideration  here,  on  account  of  the  small  quanti- 
ties employed.  The  one  drawback  of  cocain  is  its 
pupil-contracting,  or  myotic  action.  Where  this 
would  interfere  with  the  operation,  as  in  many 
iridectomies,  those  ophthalmic  surgeons  who 
generally  employ  cocain  have  recourse  to  some 
other  drug. 


OPERATIONS  ON  THE  HEAD  125 

Local  ansesthesia  is  of  special  importance  in 
operations  on  the  eye,  not  only  because  general 
anaesthesia  must  in  these  cases  be  very  deep  owing 
to  the  late  abolition  of  the  palpebral  reflex,  but 
also  because  it  is  often  desirable  during  the  opera- 
tion to  let  the  i^atient  carry  out  certain  ocular 
movements.  Vomiting,  too,  during  or  after  the 
anaesthesia,  imperils  asepsis,  and,  in  the  case  of 
incised  operation  wounds,  involves  danger  of 
opening  of  the  wound  with  all  its  consequences 
(prolapse  of  iris  and  vitreous).  Even  if  general 
asaesthesia  has  to  be  resorted  to,  local  anaesthesia 
is  called  in  as  an  auxiliary.  Fortunately,  too,  in 
the  great  majority  of  cases,  a  thoroughly  satis- 
factory anaesthesia  can  be  attained. 

For  removal  of  foreign  bodies  from  the  cornea 
2  per  cent,  cocain  solution  is  employed,  by  instilla- 
tion into  the  conjunctival  sac.  From  two  to  six 
drops  are  required.  The  same  concentration  and 
dosage  are  employed  for  the  extirpation  of  chalazia, 
for  the  painful  instillation  of  medicaments,  for 
cauterization  of  the  cornea,  and  for  other  opera- 
tions on  the  cornea  and  conjunctiva.  The  use  of 
salves  and  oily  solutions  before  operations  is  to  be 
avoided,  as  they  may  smear  over  the  site  of  opera- 
tion. The  anaesthesia  generally  comes  on  very 
quickly.  The  addition  of  suprarenin  is  not 
necessary. 

Antiesthetization  of  the  iris  is  usually  effected 


126  LOCAL  ANESTHESIA 

by  subconjunctival  instillation,  and  requires  free 
use  of  solution  and  prolonged  application.  Two  to 
5  per  cent,  solutions  are  employed,  and  the  sur- 
geon must  be  prepared  to  find  the  anaesthesia  in- 
complete, and  to  meet  with  evidences  of  slight 
pain  when  the  iris  is  interfered  with.  It  has  been 
suggested  that  the  anaesthesia  should  be  made 
more  complete  by  circular  subconjunctival  in- 
jection. Most  operators,  however,  refrain  from 
this,  as  the  resulting  chemosis  complicates  the 
operation.  The  plan  recommended  by  Haab,  too, 
of  introducing  crystals  of  cocain  into  the  anterior 
chamber,  should  only  be  employed  in  exceptional 
cases. 

Where  a  sujBficient  degree  of  anaesthesia  cannot 
be  attained,  as  in  cases  of  marked  ocular  hyper- 
aemia,  general  anaesthesia  must  be  resorted  to. 

Many  ophthalmologists  employ  in  all  intra-ocular 
operations  a  combination  of  cocain  and  suprarenin, 
others,  however,  only  in  hyperaemic  conditions, 
or  when,  owing  to  alterations  in  the  blood-vessels, 
haemorrhages  are  to  be  feared.  The  best  propor- 
tion is  5  minims  of  suprarenin  to  each  5  c.c.  of 
cocain  solution. 

For  puncture  of  the  sclerotic,  suture  of  wounds 
of  the  bulb,  and  magnet  operations,  instillation 
into  the  conjunctival  sac  is  generally  sufficient. 

Many  also  perform  strabismus  operations  under 
simple  instillation  anaesthesia.      Two  minims  of  a 


OPERATIONS  ON  THE  HEAD  127 

2  to  5  per  cent,  solution  of  cocain  are  instilled. 
The  subconjunctival  injection  of  a  2  per  cent, 
cocain- suprarenin  solution  at  the  point  where  the 
tendon  is  to  be  divided  is  very  serviceable  in,  these 
cases. 

Even  for  the  most  severe  of  all  ophthalmic 
operations,  enucleation  of  the  bulb,  local  anaes- 
thesia is,  in  many  cases,  sufficient,  and  this  is 
particularly  fortunate,  as  enucleation  is  often 
necessitated  by  morbid  conditions  of  the  eye, 
depending  on  disease  of  the  blood-vessels,  which 
render  it  desirable  to  avoid  general  anaesthesia. 
Some  [Bostely)  have  performed  enucleations  pain- 
lessly under  instillation  anaesthesia.  In  cases  of 
suppurating  panophthalmitis,  in  which  it  is  im- 
possible to  secure  anaesthesia  by  injections,  and  in 
which  general  anaesthesia  is  to  be  avoided,  one 
must  be  content  with  instillation,  though  by  this 
method  it  is  impossible  to  attain  complete  anaes- 
thesia with  any  approach  to  certainty. 

Many  and  varied  trials  have  been  made  of 
Schleich's  method  in  enucleation  operations.  It 
has,  however,  been  made  plain  by  them  that  his 
dilute  solutions  do  not  suffice  to  produce  complete 
anaesthesia. 

With  the  novocain-suprarenin  solution  employed 
to-day  the  anaesthetization  j^resents,  as  a  rule,  no 
difficulties.  After  instillation  of  a  few  drops  into 
the  conjunctival  sac  about  \  c.c.  is  injected  sub- 


128  LOCAL  ANESTHESIA 

conjunctivally  above,  below,  and  at  each  side  as 
far  as  the  equator  of  the  bulb,  a  fold  of  conjunctiva 
being  pinched  up  each  time  for  the  purpose.  From 
^  to  1  c.c.  is  then  injected  into  the  orbit,  the  can- 
nula being  passed  into  the  bulb  as  far  as  possible 
in  a  nasal  direction. 

Many  operators  use  2  per  cent,  eucain  solution, 
others  again  employ  2  per  cent,  novocain  or  alypin 
solutions  with  suprarenin. 

Anaesthesia  of  the  lips  is  very  easily  produced. 
In  place  of  a  circular  we  have  here  of  course  a 
semicircular  or  wedge-shaped  line  of  injection 
points,  the  lip  forming  the  base  of  the  triangle. 
If  anaesthesia  of  the  whole  lip  is  required,  deep 
(submucous)  injections  must  follow  the  subcuta- 
neous ones.  Even  when  the  area  of  operation 
extends  upwards  from  the  upper  lip,  or  downwards 
from  the  lower,  even  to  the  lower  border  of  the 
inferior  maxilla,  a  semicircular  or  wedge-shaped 
injection  will  be  found  quite  sufficient.  If,  how- 
ever, no  deep  injection  is  carried  out,  special 
attention  must  be  given  to  the  points  of  exit  of 
the  nerves  mentioned  above.  A  1  per  cent, 
novocain  solution  answers  every  purpose. 

With  reference  to  operations  on  the  upper  and 
lower  maxillae,  as  well  as  on  the  teeth,  a  few 
preliminary  remarks  must  be  made  : 


OPEKATIONS  ON  THE  HEAD  129 

The  infraorbital  nerve  (Fig.  13),  the  most 
important  nerve  supplying  the  upper  jaw,  passes 
from  the  pterygo- palatine  fossa  in  a  bony  canal, 
from  which  it  emerges  through  the  infraorbital 
foramen.  This  last  occupies  a  fairly  constant 
position  a  little  more  than  half  a  centimetre 
below  the  orbital  border.  The  infraorbital  nerve 
gives  off: 

1.  Before  its  entrance  into  the  bony  canal  and 
after  its  exit  therefrom  :  Branches  for  mucous 
membrane,  periosteum,  and  the  anterior  wall  of 
the  upper  jaw. 

2.  Before  it  enters  the  canal  :  Branches  which 
enter  the  bone  at  the  tuber  maxillae  behind  the 
appendage  to  the  zygomatic  process  of  the  upper 
jaw  (this  can  easily  be  felt  from  the  mouth),  and 
the  last  two  of  which  often  supply  the  first 
molars.  These  branches  are  often  joined  by 
others,  which  are  given  off  directly  from  the 
main  stem  of  the  second  ramus  of  the  trigeminus. 

3.  In  the  bony  canal  :  Branches  for  all  the 
teeth  of  the  upper  jaw,  including  the  first  molars. 

The  branches  enumerated  under  the  foregoing 
three  heads  constitute  together  the  superior 
dental  plexus  which  gives  the  rami  alveolares, 
anterior,  median  and  posterior.  The  branches 
mentioned  in  Sections  2  and  3  are  generally 
connected  with  each  other  by  an  anastomosis 
(Moral). 


130 


LOCAL  ANESTHESIA 


Further,  of  importance  to  us  as  supplying  the 
periosteum  and  the  gums  on  their  lingual  side  are 
(Fig.  13)  : 

1.  The  N.  palatinus  ant.,  which  issues  from 
the  bone  by  the  greater  palatine  foramen  at  the 
level  of  the  third  molar. 

2.  The  iV^.  nasopalatimis^  which  leaves  the  bone 
by  way  of  the  foramen  incisivum. 


Fig.  13. — Neeves  Supplying  the  Upper  Jaw. 

These  nerves  are  connected  by  an  anastomosis 
(Bmite).  Of  great  importance  in  regard  to 
local  ansesthesia  is  the  fact  that  the  nerve  fibres 
which  pass  to  the  dental  roots  from  the  dental 
plexus  lie  close  against  the  anterior  and  lateral 


OPERATIONS  ON  THE  HEAD  131 

wall  of  the  upper  maxilla,  which  is  here  exceed- 
ingly thin. 

As  regards  ansesthetization  of  the  superior 
maxilla,  we  have  seen  that  for  small  foci  on  the 
anterior  surface  circular  anaesthesia  by  deep  injec- 
tions is  quite  sufficient.  If  the  focus  is  situated 
close  to  or  above  the  point  of  exit  of  the  supra- 
orbital nerve,  it  is  advisable  to  infiltrate  this  point 
with  especial  thoroughness.  Attempts  to  anaesthe- 
tize the  whole  upper  maxilla  by  injections  into 
the  pterygo-palatine  fossa  {Matas)  have  led  to  no 
practically  useful  results,  and,  in  view  of  the 
fact  stated  above,  that  the  second  ramus  of  the 
trigeminus  often  shares  directly  in  the  inner- 
vation, they  can  hardly  be  regarded  as  very 
promising. 

Local  anaesthesia  is  of  very  great  practical 
importance  in  regard  to  dental  surgery,  especially 
for  extractions.  It  is  true  that  in  many  cases, 
especially  when  the  tooth  is  quite  loose,  the 
extraction  may  be  rendered  painless,  or,  at 
any  rate,  less  painful  by  ethyl  chloride.  The 
method,  however,  is  very  imperfect,  and  is 
steadily  giving  place  to  more  recent  ones.  As 
need  hardly  be  said,  it  is  necessary,  when  ethyl 
chloride  is  employed,  to  operate  very  quickly, 
and  the  pain  following  the  operation  is  often 
very  severe.  Ethyl  chloride  is  useful,  however, 
for    the    incision    of   small    periosteal    abscesses. 


132  LOCAL  ANESTHESIA 

which  are    completely    frozen   and    then    quickly 
incised. 

For  the  great  majority  of  dental  operations  con- 
duction anaesthesia  is  the  most  suitable  method. 
We  have  seen  that  betv/een  the  terminal  stem  of 
the  N.  dentalis  and  the  periosteum  covering  the 
anterior  bony  surface  of  the  upper  maxilla  there 
lies  a  very  thin  bony  lamella.  That  an  anaesthetic 
solution,  injected  submucously  or  subperiosteally, 
can  be  forced  directly  through  the  bone  into  the 
neighbourhood  of  the  nerve  is,  I  think,  placed 
beyond  doubt  by  experience  with  Bier's  method  of 
"  venous  "  anaesthesia.  Thus  Schleich's  procedure 
has  been  to  infiltrate  (to  the  point  of  oedema)  with 
his  dilute  (O'l  per  cent.)  cocain  solution  the  gum 
and  periosteum  in  the  neighbourhood  of  the  dental 
alveolus,  carrying  the  infiltration  to  a  level  above 
the  entry  of  the  nerve  into  the  tooth,  and  then 
to  use  the  ethyl  chloride  spray  as  an  auxiliary. 
This  method  is  now  generally  abandoned  in  dental 
practice,  for  experience  has  shown  that  it  is  not 
necessary  to  bring  pressure  to  one's  aid  in  order  to 
ensure  that  the  solution  shall  pass  through  the 
bone  and  reach  the  nerve,  but  that  it  is,  on  the 
contrary,  sufficient  to  inject  a  "  deposit "  of  a  con- 
centrated solution  just  over  the  bone,  the  solution 
then  reaching  the  nerve  by  diffusion.  It  is  true 
that  we  always  inject  under  pressure  on  the 
lingual  side,  where  the  mucous  membrane  is  pretty 


OPERATIONS  ON  THE  HEAD  133 

closely  attached  to  the  periosteum.  Even  here, 
however,  it  is  not  to  be  assumed  that  pressure 
plays  any  important  part  in  bringing  about  the 
anaesthesia,  for,  in  the  first  place,  only  a  small 
quantity  of  solution  is  injected,  and,  in  the  second, 
diffusion  through  the  bone  is  not  here  in  question, 
as  our  object  is  to  afiect  merely  the  branches  of 
the  palatine  nerves  running  between  the  mucous 
membrane  and  the  periosteum.  These  nerves, 
however,  have  nothing  to  do  with  the  innervation 
of  the  dental  pulp.  Experience  has  fully  proved 
the  applicability  in  this  connection  of  anaesthesia 
by  interruption  of  conduction.  It  is  only  necessary 
to  employ  concentrated  solutions  and  fairly  large 
additions  of  suprarenin.  Drug  absorption,  how- 
ever, appears  to  take  place  in  very  marked  degree 
in  the  neighbourhood  of  the  teeth,  and  with  the 
use  of  cocain  and  suprarenin,  symptoms  of  poison- 
ing, fortunately,  as  a  rule,  of  a  quite  transitory 
character,  have  been  observed  in  a  large  number 
of  cases.  Since  the  introduction  of  novocain  such 
toxic  symptoms  have,  according  to  many  observers, 
ceased  to  appear. 

For  dental  extractions  to-day  2  per  cent,  novo- 
cain solution  +  1  minim  of  suprarenin  to  each  cubic 
centimetre  is  generally  employed.  For  difficult 
extractions  a  slightly  larger  dose  of  suprarenin  is 
taken  (3  to  4  minims  per  2  c.c).  For  operations 
on  dentine,  resection  of  fangs,  and  other  operations 


134  LOCAL  ANESTHESIA 

hardly  coming  within  our  purview,  a  1  per  cent, 
novocain -suprarenin  solution  is  generally  em- 
ployed. According  to  the  great  majority  of 
observers  this  mixture  of  novocain  and  suprarenin 
causes  no  injury  to  the  tissues.  As,  however, 
extraction  of  teeth  is  always  accompanied  by  more 
or  less  damage  to  tissues,  sometimes  even  by 
oedema,  it  is  not  yet  possible  to  speak  decidedly 
on  the  point.  A  still  larger  volume  of  experience 
will  be  necessary  before  we  can  decide  whether 
the  free  dosage  of  suprarenin  here  requisite  is,  in 
reality,  quite  harmless  to  the  tissues.  In  order  to 
make  the  injection  itself  painless  to  very  sensitive 
patients,  a  pledget  of  cotton- wool  soaked  in  20  per 
cent,  novocain  solution  may  be  kept  applied  to  the 
mucous  membrane  for  ten  to  fifteen  minutes 
jDreviously. 

In  order  to  render  painless  the  extraction  of  an 
upper  tooth,  we  elevate  the  lip  and  inject  0'5  to 
1*5  c.c.  of  2  per  cent,  novocain-suprarenin  solution 
on  the  labial  side  of  the  tooth,  passing  the  needle 
horizontally  deep  into  the  space  between  mucous 
membrane  and  periosteum  over  the  affected  tooth, 
at  the  level  of  the  fold  where  the  labial  or  buccal 
mucous  membrane  passes  over  to  that  of  the 
gums.  For  the  two  last  molars,  however,  whose 
nerves  course  over  the  bone  above  the  tuber 
maxillae,  we  inject  the  solution  behind  the  easily 
felt  zygomatic  process  in  a  more  vertical  direction. 


OPEEATIONS  ON  THE  HEAD  135 

We  always  inject  from  within  outwards,  so  that 
the  solution  leaves  the  needle  at  a  point  above,  and 
somewhat  lateral  to,  the  tooth  to  be  anaesthetized. 
For  injection  on  the  lingual  side  but  little  solution 
is  required,  0'25  to  0*5  c.c,  so  that  for  the  extrac- 
tion of  one  or  two  teeth  hardly  more  than  0'2  c.c. 
of  solution  is  required  in  all.  The  solution  is  in- 
jected deeply  into  the  gum  on  the  lingual  side  of 
the  tooth.  Fairly  strong  pressure  is  needed,  as 
the  mucous  membrane  and  periosteum  are  closely 
connected.  Infiltration  of  the  point  of  exit  of  the 
palatine  nerves  is  only  necessary  where  a  number 
of  teeth  are  to  be  extracted.  If  it  is  desired  to 
"catch"  the  N.  palati?iits  anterior  at  a  central 
point,  it  will  be  necessary  to  inject  also  at  the  fora- 
men incisivum  of  the  N,  nasopalatinus,  as  the  two 
nerves  are  connected  by  a  loop.  The  point  of  exit 
of  the  N.  palatmus  anterior  lies  opposite  the  last 
molar  tooth,  and  about  1  centimetre  mesial  to  it, 
that  of  the  N.  nasopalatinus  in  the  middle  line, 
J  to  1  centimetre  behind  the  central  incisor  teeth. 
The  period  of  waiting  required  is  about  five 
minutes.  After  ten  minutes  one  may  be  sure 
that  the  effect  will  be  fully  developed  if  the 
injection  has  succeeded  at  all. 

For  operations  on  the  hard  palate  it  is  sufficient 
to  bear  in  mind  the  above-mentioned  points  of  exit. 
A  1  per  cent,  solution  generally  suffices,  as  also 
for  operations  on  the  soft  palate,  which  is  either 


136  LOCAL  ANESTHESIA 

infiltrated  diffusely  or  cut  off  from  its  sensory- 
nerves  by  a  semicircular  injection  along  the 
border  between  soft  and  hard  palates. 

There  remains  to  be  considered  the  method  of 
producing  anaesthesia  for  the  operation  of  opening 
the  antrum  of  Highmore.  This  can  almost  always 
be  successfully  performed  under  local  anaesthesia. 
If  the  antrum  is  to  be  opened  through  an 
alveolus  the  procedure  is  exactly  the  same  as  for 
an  extraction,  except  that  the  anterior  surface 
should  be  somewhat  more  freely  injected.  Tre- 
phining the  antrum,  by  way  of  the  anterior  surface 
of  the  maxilla,  is  also  free  from  difficulty  as 
regards  local  anaesthesia. 

Free  submucous  infiltration  is  made,  with 
1  per  cent,  novocain-suprarenin  solution,  of  the 
whole  of  the  anterior  surface  in  the  neighbour- 
hood of  the  selected  site  of  operation.  In 
addition,  the  needle  is  passed  as  high  as  possible 
in  order  to  leave  a  few  cubic  centimetres  of 
solution  about  the  point  of  exit  of  the  infra- 
orbital nerve.  After  waiting  five  minutes  the 
trephining  can  then  be  carried  out  quite 
painlessly. 

By  this  latter  method  the  mucous  membrane  is 
anaesthetized  over  the  greater  portion  of  the 
facial  wall  of  the  antrum.  If,  however,  the 
mesial  wall  here  is  to  be  interfered  with,  the 
mucous    membrane  must,  after  the  opening  has 


OPEEATIONS  ON  THE  HEAD  137 

been  made,  be  painted  with  20  per  cent,  novocain 
solution. 

For  the  opening  of  Highmore's  antrum  from 
the  lower  nasal  passage,  injection  into  the  muco- 
periosteal  covering  of  that  region  is  sufficient. 
If  the  opening  is  to  be  made  from  the  border  of  the 
pyriform  aperture,  deep  injections  from  the  mouth, 
pushed  to  the  extent  of  elevation  of  the  perios- 
teum, will  produce  a  sufficient  ansesthesia ;  the 
cutting  of  the  bone  is,  however,  generally  found 
hard  to  bear  owing  to  the  vibration  caused  by  the 
trephine. 

The  nerve  suj)ply  of  the  lower  maxilla  is  as 
follows  (Fig.  14) : 

1.  The  N.  alveolar  is  inferior  supplies  the  peri- 
osteum and  pulp  of  all  the  teeth,  as  also  the 
gums  and  alveolar  periosteum  on  their  labial 
side. 

2.  The  N.  lingualis  supplies  the  lingual  side  of 
gums  and  alveolar  periosteum. 

The  N.  alveolaris  inferioi^  enters  the  lower  jaw- 
bone on  its  medial  side  at  the  so-called  lingula. 
Before  it  enters  the  bone  it  runs  for  a  space 
along  the  inner  surface  of  the  latter  about  1-^  centi- 
metres behind  the  N.  lingualis.  During  its  course 
within  the  bone  the  N.  alveolaris  inf.  gives  off 
branches  for  the  dental  roots  {Plexus  dentalis 
vnferior)  and  the  gums.  One  branch,  the  N. 
mentalisy  emerges  from  the    bone  about  opposite 


138  LOCAL  ANESTHESIA 

the  first  bicuspid — the  point  of  exit  is  not  very 
constant — and  takes  part  in  the  innervation  of 
the  labial  gums.  In  the  middle  line  there  are 
numerous  anastomoses  between  the  nerves. 

As  regards  the  ansesthetization  of  the  teeth 
of  the  lower  jaw,  the  general  principles  laid 
down  above  in  connection  with  the  upper  jaw 
apply  here  mutatis  mutandis. 


Ill L 


N.  lingualis 

N.  alveo- 
laris  inf. 


Fig.  14. — Nerves  of  the  Lower  Jaw. 

Many  dentists  employ  for  all  the  lower  teeth, 
at  any  rate  for  all  single  extractions,  the  method 
of  sub-gingival  injection  above  described.  The 
majority,  however,  while  adopting  this  method 
for  the  mesial  teeth,  including  the  canines  or  even 
the  first  bicuspids,  employ  the  method  of  anaesthesia 
by  interruption  of  conduction  in  the  N.  alveolaris 
inf.  for  the  lateral  teeth.  Others,  again,  combine 
both  methods. 

Interruption     of    conduction    in    the    inferior 


OPERATIONS  ON  THE  HEAD  139 

alveolar  nerve,  and  in  the  lingual  nerve,  after 
Halsted's  method,  is  not  an  easy  matter  for  the 
beginner  in  local  anaesthesia,  and  gives  good 
results  only  to  those  of  wider  experience.  The 
technique  has  been  elaborated  chiefly  by  Hiibner 
and  Braun  :  the  mouth  being  open,  the  sharp 
anterior  border  of  the  coronoid  process  of  the 
lower  jaw  is  felt  behind,  and  slightly  lateral  to, 
the  third  molar  tooth,  a  little  internal  to  this 
again  is  another  bony  ridge,  the  linea  ohliqua 
{interna).  Close  to  this,  and  about  one  centi- 
metre above  the  masticatory  surface  of  the  molars, 
lies  the  lingual  nerve  immediately  beneath  the 
mucous  membrane.  Passing  now  backwards  in  a 
direction  parallel  to  the  upper  surface  of  the 
molar  teeth,  and  keeping  close  to  the  bone,  one 
comes  upon  the  inferior  alveolar  nerve  about 
l\  centimetres  behind  the  lingual,  and  just  before 
its  entry  into  the  bone. 

The  solution  generally  used  for  injection  here  is 
a  2  per  cent,  novocain  solution  +  1  to  2  minims 
of  suprarenin  per  cubic  centimetre.  The  index 
finger  is  passed  into  the  mouth  over  the  last 
molar  tooth,  until  the  extremity  of  the  nail,  the 
surface  of  which  looks  towards  the  middle  line, 
meets  the  linea  obliqua.  The  needle  is  then 
inserted  about  1  centimetre  above  the  last  molar 
(not  too  far  in  a  mesial  direction)  until  the  bone  is 
felt ;    it  is  then   withdrawn    slightly,   and  about 


140 


LOCAL  ANAESTHESIA 


•25  c.c.  injected  for  the  A^.  lingualis.  For  the  N. 
alveolar  is  inf.  the  needle  is  pushed  on  backwards 
for  a  distance  of  1^  centimetres,  always  keeping 
close  to  the  bone  and  maintaining  a  direction 
parallel  to  the  molar  masticating  surface.  Dur- 
ing the  passage  of  the  needle  the  remainder  of 

the  solution  is  injected, 
thus  about  1  c.c.  in  all. 
(Fig.  15.) 

After  about  5  minutes 
anaesthesia  comes  on  in 
the  region  supplied  by 
the  lingual  nerve.  For 
the  inferior  alveolar  nerve 
it  is  necessary  to  wait 
20  minutes  or,  to  be  safer, 

half  an  hour.  Failures 
Fig.  15. — Anesthetization  of 

THE    Inferior    Alveolar   are     by     no     means     un- 

Nerve  (Braun)  ^^^^^  ^^^^  ^^  practised 

a.  Bony  ndge.  ^  ^ 

operators.  With  a  view 
to  their  avoidance,  Blinte  has  recommended  that, 
in  view  of  an  anastomosis  which  is  frequently 
present,  some  solution  shall  be  injected  at  the 
point  of  exit  of  the  N.  mentalis  (below  the  first 
or  second  bicuspid).  It  may  be  further  pointed 
out  that  the  point  of  entry  of  the  N.  aheolaris 
inferior  into  the  bone  is  at  a  lower  level  in  chil- 
dren and  the  aged  than  in  young  adults. 

In  carrying  out   the    sub-gingival    method   of 


OPERATIONS  ON  THE  HEAD  141 

anaesthetizing  the  teeth  of  the  lower  jaw,  it 
should  be  remembered  that  the  bone  is  thicker 
and  denser  on  its  labial  side  than  that  of  the 
upper  jaw,  therefore  the  dose  of  solution  injected 
must  not  be  too  small.  The  technique  of  injection 
is  the  same  as  already  described  for  the  upper 
teeth,  except  that  on  the  lingual  side  the  injection 
must  be  made  at  the  fold,  where  the  mucous 
membrane  of  the  gums  joins  that  of  the  floor  of 
the  mouth.  It  is  also  important  that  the  solution 
should  be  injected  a  little  behind  the  affected 
tooth.  The  method  is  not  quite  certain  for  the 
lower  molars,  though  the  results  are  often 
perfectly  satisfactory. 

As  regards  other  operations  in  the  region  of 
the  lower  jaw»  the  most  important,  from  a  practical 
point  of  view,  is  the  incision  of  a  parulis.  Here, 
where  we  have  to  do  generally  with  large 
inflammatory  swellings  closely  connected  with 
the  deeper  tissues,  circular  anaesthesia  is  not 
generally  found  to  give  the  results  desired.  If, 
as  is  most  frequently  the  case,  we  have  merely 
to  open  an  abscess,  Schleich's  infiltration  method 
is  the  most  suitable.  As  has  been  stated,  it  is 
generally  possible  to  infiltrate  painlessly  the 
stretched,  and  only  secondarily  involved,  skin. 
No  wheal  is  formed,  but  merely  a  diffuse  oedema. 
If  the  infiltration  is  carried  step  by  step  into 
the  deeper  tissues,  the  abscess  can  generally  be 


142  LOCAL  ANESTHESIA 

incised  painlessly,  and  the  wound  then  somewhat 
enlarged.  If  it  is  necessary  to  deal  with  the 
bone  itself,  which  in  these  abscesses  is  seldom  the 
case,  it  is  safer  to  anaesthetize  the  inferior 
alveolar  nerve  by  the  method  we  have  described, 
and,  in  addition,  to  inject  the  whole  area  of 
operation.  As  a  rule,  however,  general  anaesthesia 
is  to  be  preferred  in  these  cases,  especially  as  a 
certain  amount  of  immobility  of  the  jaw  often 
prevents  injection  of  the  nerve. 

For  operations  on  quite  superficial  morbid  foci 
affecting  the  lower  maxilla,  the  method  of  circular 
analgesia  with  a  special  injection  at  the  point  of  exit 
of  the  iV.  mentalis  will  be  found  to  answer  every 
purpose. 

It  is  easy  also  to  produce  a  satisfactory 
anaesthesia  for  operations  on  the  middle  ne,  as, 
for  instance,  suture  of  a  broken  maxilla.  A  fairly 
long  needle  is  inserted  at  the  chin  and .  a  free 
infiltration,  subcutaneous,  submucous,  and,  so 
far  as  possible,  subperiosteal,  is  carried  out, 
both  before  and  behind  the  bone,  with  1  per 
cent,  novocain  solution.  A  finger  inserted  into 
the  mouth  feels  and  controls  the  needle  through 
the  labial  or  lingual  mucous  membrane.  One 
needle  puncture  is  generally  sufficient  in  view  of 
the  free  movability  of  the  skin.  If  a  tooth  has 
to  be  extracted,  the  neighbourhood  of  its  alveolus 
must   be    specially  freely    infiltrated  ;    free    sub- 


OPERATIONS  ON  THE  HEAD  143 

cutaneous  infiltration  is  then  carried  out  on  either 
side  of  the  line  of  incision,  the  lips  being  of  course 
also  infiltrated  if  necessary.  It  is  not  necessary 
to  infiltrate  specially  about  the  mental  foramen. 

If  the  area  of  operation  is  more  laterally  situated 
conduction  is  first  interrupted  in  the  inferior 
alveolar  and  lingual  nerves  in  the  manner  already 
described,  the  soft  parts  involved  being  then 
anaesthetized  by  circular  infiltration.  In  suture 
of  the  horizontal  ramus  of  the  lower  maxilla  this 
interruption  of  conduction  is,  according  to  Braun, 
not  necessary.  From  points  about  2  centimetres 
on  either  side  of  the  point  of  fracture  he  infil- 
trates the  anterior  and  posterior  surfaces  of  the 
bone,  and  also  the  subcutaneous  and  submucous 
cellular  tissues,  as  described  above  for  operations 
on  the  middle  line.  After  exposure  of  the  frac- 
tured ends  he  injects  a  little  concentrated  solution 
into  the  lateral  opening  of  the  bony  canal  for  the 
nerve. 

Of  other  operations  about  the  lower  jaw  mention 
need  only  be  made  of  extirpation  of  glands  from 
the  submaxillary  region,  which,  unless  the  glands 
are  adherent  to  the  subjacent  tissues,  can  be 
carried  out  quite  painlessly  under  circular  analgesia 
(using  preferably  1  per  cent,  novocain  solution). 

The  same  applies  to  operations  on  the  cheek  and 
the  floor  of  the  mouth. 

As   regards   operations   on    the    tongue — it   is 


144  LOCAL  ANESTHESIA 

only  for  the  anterior  half  of  the  organ  that  local 
anaesthesia  comes  into  question  at  all — the  method 
of  circular  analgesia  is  quite  effective.  Braun  first 
anaesthetizes  the  tip  of  the  tongue  by  submucous 
infiltration,  and  passes  a  strong  retaining  thread 
through  it.  It  is  not  possible  to  produce  with 
certainty  anaesthesia  of  any  part  of  the  tongue  by 
interruption  of  conduction  in  the  larger  nerve 
trunks. 

No  attempt  should  be  made  to  operate  on  large 
carcinomata  of  the  tongue  under  local  anaesthesia, 
as  in  these  cases  the  glands  are  almost  always 
involved,  and  a  complete  and  radical  removal  is 
necessary. 


CHAPTER  IX 

OPERATIONS  ON  THE  CERVICAL  REGION 

Although  the  internal  organs  of  the  cervical 
region  are  in  chief  part  supplied  by  three  nerves 
{auricularis  magnus,  cutaneus  colli,  and  supra- 
clavicularis),  which  are  fairly  easily  reached  at  the 
point  where  they  emerge  at  the  posterior  border 
of  the  sternocleido-mastoid,  the  ansesthetization  of 
these  nerve-trunks  has  not,  in  consequence,  ap- 
parently, of  the  numerous  anastomoses  between 
these  and  other  nerves  in  the  neighbourhood, 
established  itself  as  a  practical  method.  For  the 
most  important  operations  in  this  region,  extirpa- 
tion of  cervical  glands  and  strumectomies,  the 
method  of  circular  analgesia  is  exclusively  em- 
ployed. 

In  the  extirpation  of  cervical  glands,  however, 
local  anaesthesia  is  but  of  limited  appHcation,  and 
must  not  be  employed  save  where  the  glands  are 
fairly  superficial,  and  are  easily  separable  from 
their  surroundings.  For  the  removal  of  small 
glands  a  free  infiltration  is  made  of  1  per 
cent,    novocain  solution,  a  0*5  per  cent,  solution 

145  10 


146  LOCAL  ANESTHESIA 

being  employed  if  the  area  of  operation  is  more 
extensive.  In  those  cases,  however,  where  a  long 
chain  of  larger  and  smaller  glands  extends  into 
the  deeper  tissues  along  the  large  bloodvessels 
general  anaesthesia  must  be  resorted  to  in  pre- 
ference ;  otherwise  one  will  frequently  be  placed 
in  the  embarrassing  position  of  having  to  continue 
under  general  an  operation  begun  under  local 
anaesthesia.  For  the  simple  incision  of  lympha- 
denitic  abscesses  the  rules  above  laid  down  with 
reference  to  parulis  hold  good. 

The  matter  is  more  complicated,  however,  if  it 
is  desired  to  scrape  out  an  abscess  cavity  which 
extends  deeply  and  is  adherent  to  the  subjacent 
parts,  so  that  it  is  impossible  to  inject  all  round  it. 
In  such  a  case  we  must  adopt  Schleich's  method, 
and,  as  the  incision  is  deepened,  infiltrate  step  by 
step  the  deeper  layers,  always  proceeding  from 
the  healthy  towards  the  diseased  tissues.  This 
rule  should  be  strictly  adhered  to.  On  the  other 
hand,  in  removing  an  aseptic  cystic  tumour  which 
is  connected  with  the  deeper  tissues,  so  that  the 
method  of  primary  circular  anaesthesia  is  imprac- 
ticable, the  deeper  layers  may  be  infiltrated 
directly  from  the  operation  wound.  At  the  same 
time  the  beginner,  at  any  rate,  should  realize  that 
in  all  these  conditions  it  is  inadvisable  to  form  too 
wide  a  conception  of  the  indications  for  local  anaes- 
thesia. 


OPEEATIONS  ON  THE  CEKVICAL  REGION    147 

Local  anaesthesia  has  very  rapidly  advanced  in 
the  favour  of  surgeons  for  the  removal  of  a 
bronchocele.  Formerly  the  greater  part  of  the 
operation  could  be  carried  out  painlessly  ;  as  soon, 
however,  as  it  came  to  the  actual  dislocation  of 
the  thyroid  gland,  the  methods  then  in  use  failed 
as  a  rule.  As  methods  have  been  perfected  it  has 
become  possible  to  secure  that  this  part  of  the 
operation  also  shall  be  performed  painlessly  in  the 
majority  of  cases.  There  is  still  a  good  deal  of 
difference  of  opinion  with  regard  to  the  ^Droportion 
of  cases  in  which  local  anoesthesia  is  indicated. 
Many  operators  always  remove  the  thyroid  gland, 
even  in  cases  of  retrosternal  extension,  under  local 
anaesthesia  ;  it  must  be  admitted,  however,  that 
in  the  more  difficult  cases  of  thyroid  excision  the 
anaesthesia  is  by  no  means  completely  to  be  relied 
on,  especially  during  the  luxation  of  the  gland. 
The  solution  generally  employed  is  a  0*5  per  cent, 
novocain  -  suprarenin  solution.  As  regards  the 
dosage  of  suprarenin,  marked  differences  of  opinion 
prevail.  Bier,  for  instance,  adds  1  minim  and 
Hackenbruch  4  minims  (both  non-synthetic  supra- 
renin) to  each  10  c.c.  of  solution.  I  have  found 
the  addition  of  1  to  2  minims  of  synthetic  supra- 
renin per  10  c.c.  answer  every  purpose. 

In  small  bronchoceles,  for  which  not  more  than 
50  or  GO  c.c.  of  solution  are  required,  it  is,  in  my 
opinion,   quite   suitable   to  employ  a   1   per  cent. 


148  LOCAL  ANAESTHESIA 

novocain  solution.  Of  the  O'o  per  cent,  solution 
we  may  inject  without  misgiving  100  c.c.  or  more. 
Some  surgeons  use  alypin  (0'5  to  1  per  cent,  solu- 
tion) +  suprarenin,  and  also  report  good  results. 

The  technique  of  circular  injection  in  these  cases 
is  very  simple.  It  is  best  to  inject  at  four  points 
(which  may  be  first  rendered  anaesthetic  by  the 
cutaneous  wheal  method),  first  at  the  border  of 
the  sterno-mastoid  deep  into  the  connective  tissue 
surrounding  the  bronchocele,  in  the  direction  fol- 
lowed by  the  great  bloodvessels,  and  then  above 
and  below  as  deeply  as  possible  beneath  the  fascia. 
A  complete  surrounding  injection  of  the  deeper 
tissues  is  often  impossible ;  it  is,  however,  suf- 
ficient to  pass  the  needle  as  far  as  possible  under 
the  tumour.  The  injection  of  the  deeper  tissues 
must  follow^  the  circular  subcutaneous  injection. 
Finally,  the  neighbourhood  of  the  isthmus  is 
injected.  To  guard  against  injecting  into  a  vein 
the  needle  should  be  withdrawn  after  making  the 
puncture,  so  as  to  satisfy  oneself  that  no  blood 
issues.  As  an  additional  precaution,  the  needle 
may  be  kept  constantly  moving  during  the  injec- 
tion. After  the  injection  is  completed,  sufficient 
time  (at  least  ten  to  fifteen  minutes)  must  be 
allowed  for  anaesthesia  to  develop.  The  anaesthesia 
will  last  long  enough  unless  the  operator  is  abnor- 
mally slow.  Morphine  is  administered  beforehand 
to  excitable  patients  by  many  surgeons,     Hacken- 


OPERATIONS  ON  THP]  CERVICAL  REGION     149 

bruch  gives  two  closes  of  tincture  of  opium,  the 
first  an  hour  and  the  second  half  an  hour  before 
the  operation,  and  maintains  that,  in  this  way, 
the  vomiting  often  observed  during  the  operation 
when  morphine  has  been  injected  is  avoided.  In 
my  opinion,  however,  better  results  are  obtained 
without  the  use  of  narcotics. 

Among  other  operations  on  the  cervical  region 
tracheotomy  can  be  performed  satisfactorily  under 
circular  anaesthesia.  The  needle  is  inserted  on 
either  side,  a  centimetre  or  two  from  the  middle 
of  the  line  of  incision,  and  a  0*5  or  1  per  cent, 
novocain  +  suprarenin  solution  is  infiltrated  into 
the  surrounding  tissues,  with  special  thoroughness 
into  the  deeper  tissues  at  the  sides  of  the  trachea 
and  around  the  lower  part  of  the  larynx,  finishing 
with  a  subcutaneous  infiltration. 

For  the  ansesthetization  of  the  laryngeal  mucous 
membrane  it  is  generally  sufiicient  to  apply  a 
20  per  cent,  novocain  solution  to  which  3  minims 
of  suprarenin  per  cubic  centimetre  have  been 
added.  About  3  c.c.  of  this  solution  in  all  are 
employed,  in  separate  applications,  at  intervals  of 
three  to  four  minutes.  Alypin  in  20  to  25  per 
cent,  solution  is  also  employed  in  these  cases  by  a 
number  of  surgeons  ;  others,  again,  hold  to  cocain, 
maintaining  that  it  is  the  most  reliable  anaesthetic 
for  this  mucous  membrane.  As,  however,  20  per 
cent,  solutions  are  generally  necessary,  the   need 


150 


LOCAL  ANESTHESIA 


N.  laryng.  sup. 


for  some  method  other  than  that  of  external 
apph cation  to  the  membrane  has  been  strongly 
felt.  Frey  has  anaesthetized  the  laryngeal  mucous 
membrane  by  interruption  of  conduction  in  the 
nerve  which  supplies   it,  the  superior  laryngeal. 

This  nerve  supplies 
the  mucous  mem- 
brane, from  the  epi- 
glottis to  the  vocal 
cords,  with  sensory 
fibres.  Below,  the 
glottis  fibres  of  the 
inferior  laryngeal 
nerve  also  take  part 
in  the  innervation,  so 
geuS"  tl^at  here  the  anaes- 
thesia is  no  longer  re- 
liable. The  superior 
laryngeal  nerve 
passes  through  the 
hyothyroid  mem- 
brane into  the  larynx, 
and  can  be  reached  at  the  point  at  which  this  pas- 
sage takes  place  (Fig.  16).  About  1  c.c.  of  a 
2  per  cent,  novocain-suprarenin  solution  is  in- 
jected on  either  side,  the  operator  selecting  a 
point  midway  between  the  greater  cornu  of  the 
hyoid  bone  and  the  upper  border  of  the  thyroid 
cartilage,   and,   in  strong  adults,  about   3   centi- 


FiG.  16. — Nerves  of  the 
Larynx. 


OPERATIONS  ON  THE  CERVICAL  REGION    151 

metres  from  the  middle  line.  The  needle  is 
passed  horizontally  and  slightly  towards  the 
middle  line.  The  patient  is  told  not  to  swallow 
during  the  injection,  as  this  causes  a  change 
in  the  relative  positions  of  the  parts.  The 
solution  is  ejected  at  the  point  where  the  nerve 
enters  the  membrane— some  surgeons  pass  the 
needle  through  the  membrane  and  then  inject. 
The  anaesthesia  reaches  its  height  in  from  ten  to 
fifteen  minutes,  and  lasts  in  usable  degree  for 
about  twenty  minutes.  It  may,  however,  last 
much  longer,  even  in  some  cases  from  one  to  two 
hours.  It  is,  of  course,  necessary  to  add  to  the 
injection  a  local  application  to  the  fauces  in  order 
to  cut  off  the  faucial  reflex. 

Hecently  {Biei')  many  major  operations  on  the 
larynx — in  particular,  extirpation — have  been 
carried  out  under  local  anaesthesia.  For  this, 
interruption  of  conduction  in  the  superior  laryn- 
geal is  not  sufficient.  It  is  necessary,  in  addition, 
to  inject  around  the  whole  larynx  with  0*5  per 
cent,  novocain-suprarenin  solution.  Two  cuta- 
neous wheals  on  either  side  of  the  larynx  are 
generally  sufficient,  so  far  as  the  skin  is  concerned. 
The  deeper  parts  on  either  side  of  the  larynx  and 
trachea  are  freely  infiltrated,  and  a  circular  sub- 
cutaneous infiltration  is  added.  If  the  technique 
for  anaesthesia  of  the  superior  laryngeal  is  correctly 
carried  out,  the  local  application  to  the  ixiucous. 


152  LOCAL  ANESTHESIA 

membrane,  which  formerly  accompanied  the  cir- 
cular injection,  will  be  found  hardly  necessary. 

Circular  anaesthesia  is  quite  reliable  for  the 
incision  of  boils  or  carbuncles  at  the  back  of  the 
neck  In  view  of  the  rich  blood-supply  in  this 
region,  the  dose  of  suprarenin  should  not  be  too 
small.  In  very  large  carbuncles  it  is  often  not  an 
easy  matter  to  ensure  complete  painlessness  if  the 
latter  is  to  include,  as  is,  of  course,  to  be  desired, 
the  injection  itself  As  the  inflammation  here 
extends  far  into  the  deeper  tissues,  it  is  often 
necessary  to  inject  subcutaneously  into  the  healthy 
area  all  round  the  carbuncle  (preferably  with 
1  per  cent,  solution),  and  then,  after  allowing  a 
short  time  for  the  diflusion  of  the  solution,  to  pro- 
ceed to  infiltrate  gradually  the  deeper  parts.  In 
order  to  ensure  complete  anaesthesia  it  is  necessary 
to  inject  freely  beneath  the  inflamed  area,  for,  in 
the  first  place,  fairly  large  sensory  branches  pass 
outwards  through  the  fascia  ;  and,  secondly,  the 
pressure  of  the  knife  in  making  the  incision  causes 
a  compression  of  the  deeper  parts  which,  if  the 
anaesthesia  be  incomplete,  gives  rise  to  severe 
pain. 


CHAPTER  X 

OPERATIONS  ON  THE  THORAX 

Operations  on  innocent  mammary  tumours  are 
particularly  suitable  for  local  anaesthesia.  The 
ordinary  surrounding  injection,  with,  if  the  tumour 
is  extensive,  an  infiltration  of  the  retro-mammary 
tissue,  is  sufficient  in  all  cases. 

For  malignant  tumours  of  the  breast,  on  the 
other  hand,  local  anaesthesia  must  be  entirely  dis- 
carded, since,  even  if  the  removal  of  the  mamma 
itself  were  possible,  the  radical  extirpation  of  the 
axillary  glands  could  not  be  carried  out  painlessly 
under  any  local  anaesthetic  method. 

Operations  for  suppurative  mastitis  are  quite 
feasible  under  local  anaesthesia,  especially  if 
one  confines  oneself  to  small  incisions  and  then 
employs  Bier's  suction  apparatus.  In  circum- 
scribed suppurations  one  can,  of  course,  inject 
all  round  the  diseased  focus.  In  the  more  severe 
cases,  however,  it  is  best  to  have  recourse  to 
Schleich's  infiltration  method.  The  stretched 
and  only  secondarily  inflamed  skin  as  a  general 
rule  admits,  as  is  the  case  with  gumboils,  of  the 

153 


154  LOCAL  ANvESTHESIA 

injection  being  carried  out  painlessly.  It  is 
necessary  here,  however,  to  operate  with  great 
caution  and  to  avoid  interference  with  the  deeper 
parts  of  the  inflamed  area.  For  manipulations  of 
the  latter  kind,  especially  for  dilatation  of  the 
abscess  with  the  finger  or  with  forceps,  local 
anaesthesia  is  only  effective  if  injections  are  made 
all  round  and  beneath  the  area  of  operation. 

In  puncture  of  the  pleura,  infiltration  of  the  sub- 
cutaneous and  deeper  tissues  will  enable  the  small 
operation  to  be  carried  out  quite  painlessly. 

Of  operations  on  the  bony  thorax,  the  one  most 
commonly  performed  under  local  anaesthesia  is  the 
resection  of  ribs  for  the  evacuation  of  an  empyema. 
We  have  seen  in  a  previous  chapter  that  it  is  not 
always  necessary  to  inject  beneath  the  periosteum 
in  order  to  render  the  bone  anaesthetic  by  inter- 
ruption of  conduction,  but  that  it  is  often  sufficient 
to  inject  freely  into  the  deeper  tissues  adjoining 
the  periosteum.  Two  points  therefore  are  marked, 
one  below  and  one  above  the  middle  of  the  chosen 
line  of  incision,  and  from  these  1  per  cent,  novo- 
cain-suprarenin  solution  is  injected  all  round  the 
section  of  bone  to  be  removed  so  that  it  is,  so  far 
as  is  practicable,  bathed  in  the  solution.  We  inject 
first  at  the  lateral  then  at  the  mesial  border 
beneath  the  rib,  then  in  the  deeper  tissue-layers 
above  it.  It  is  advisable  also  to  bathe  the  rib  in 
anaesthetic  solution  at  the  middle  of  the  line  of 


OPERATIONS  ON  THE  THORAX  155 

incision  ;  so  that  we  have  here  no  pure  conduction 
anaesthesia.  The  whole  operation  area  is  then 
subcutaneously  injected.  A  dose  of  50  to  60  c.c. 
of  solution  is  usually  sufficient.  Should  it  not 
prove  so  the  injection  should  be  completed  with 
0'5  per  cent,  solution. 

If  it  is  wished  to  proceed  by  Schleich's  method 
the  subcutaneous  cellular  tissue  and  musculature 
are  first  infiltrated,  then  the  anterior  and  pos- 
terior borders  of  the  rib,  so  far  as  possible  sub- 
periosteally.  The  rib  is  then  resected  and  the 
pleura  infiltrated  separately. 

What  has  been  said  with  reference  to  the  ribs 
applies  also  to  their  cartilages.  I  have,  for 
instance,  carried  out  entirely  painlessly  by  this 
method  a  Frcund's  operation  (resection  of  the  first 
to  the  fourth  costal  cartilages).  The  ansesthetiza- 
tion  of  the  first  rib  presents  some  difficulty  in 
these  cases.  It  must  be  freely  bathed  in  1  per 
cent,  solution.  Here,  in  view  of  the  near  neigh- 
bourhood of  large  bloodvessels,  special  care  must 
be  taken  to  keep  the  syringe  always  in  movement 
during  the  infiltration. 

Anaesthetization  for  operations  on  the  clavicle  is, 
on  the  contrary,  a  very  simple  matter,  for  which 
there  is  no  necessity  to  add  to  the  rules  laid  down 
in  the  foregoing. 

Carious  foci  in  the  ribs  or  sternum  can  also  be 
operated  on  successfully  under  circular  anaesthesia, 


156  LOCAL  ANESTHESIA 

provided  that  the  extent  of  the  diseased  area,  and 
so  of  the  possible  field  of  operation,  is  accurately 
known  beforehand.  It  is  then  only  necessary  to 
be  sure  that  the  deeper  tissues  are  sufficiently 
infiltrated.  Even  when  the  disease  is  found  to 
extend  farther  than  was  expected  it  is  often 
possible,  with  a  stout  needle,  to  infiltrate  the  bone 
marrow  freely  from  the  opening  made  into  the 
medullary  cavity,  and  so  again  attain  an  anaesthetic 
condition. 


CHAPTER  XI 
OPERATIONS   ON   THE  EXTREMITIES 

We  are  here  in  a  region  in  which  our  knowledge 
is  at  the  present  time  very  largely  in  a  state  of 
flux.  Bier's  '  venous '  anaesthesia  has  won  quite 
new  prospects  for  local  anaesthesia,  and  we  may 
confidently  expect  that  before  long  we  shall 
succeed  in  changing  the  "  encouraging  results " 
and  "  failures,"  which  are  to-day  reported,  into 
complete  successes.  For  major  operations  on  the 
extremities,  especially  for  amputations  and  re- 
sections, local  anaesthesia  has  not  as  yet,  in  spite 
of  isolated  successes,  become  really  popular ;  in 
the  lower  extremity,  spinal  anaesthesia  has 
offered  a  substitute.  It  is,  however,  worth 
endeavouring  to  supersede  this  method,  which  is 
by  no  means  free  from  danger,  by  local  anaesthesia, 
where  it  can  be  applied.  Wherever  possible  we 
shall  prefer  our  older  methods  to  that  of  venous 
anaesthesia,  if  only  for  their  greater  convenience. 

Among  operations  on  the  shoulder  and 
axillary  region  those  on  glandular  abscesses 
offer  the  most  frequent  occasion   for  the  employ- 

157 


158  LOCAL  ANESTHESIA 

ment  of  local  anaesthesia.  What  has  been  said 
above  as  regards  the  cervical  region  applies  here 
also.  Foci  M^hich  are  adherent  to  the  subjacent 
tissues  are  difficult  to  ansethetize,  unless  a  super- 
ficial incision  is  all  that  is  required.  Only  in  the 
case  of  secondarily  inflamed  skin  should  one  begin 
by  infiltrating  a  diseased  tissue.  In  other  cases 
it  is  necessary,  following  Schleich's  practice,  to 
proceed  gradually  from  the  healthy  to  the  diseased 
tissues. 

I  have  several  times  operated  on  subdeltoid 
bursse  under  local  anaesthesia.  As  these  are 
generally  connected  with  the  shoulder  joint,  or  at 
any  rate  lie  very  close  to  it,  it  is  as  a  rule  only 
possible  to  infiltrate  the  deeper  tissues  after 
incision  through  the  more  superficial  layers. 

Crile  has  performed  an  exarticulation  of  the 
shoulder  by  the  aid  of  endoneural  injection  into 
the  brachial  plexus,  which  he  exposed  at  the 
posterior  border  of  the  sternocleido-mastoid.  He 
injected  into  each  nerve  enough  solution  to 
produce  a  slight  bulging.  The  operation  was 
painless,  except  as  regards  the  skin  incision. 

I  mention  the  method,  because,  in  exceptional 
cases,  if  general  anaesthesia  is  contraindicated,  it 
may  be  worth  considering  as  a  last  resort.  It 
should  hardly  be  employed  as  a  method  of  election. 

Most  operations  on  the  superficial  tissues  of  the 
upper  arm,  elbow,  and  forearm  can  be  performed 


OPERATIONS  ON  THE  EXTREMITIES         159 

under  local  anaesthesia.  It  is  employed  very 
frequently  for  operations  on  the  olecranon  bursa. 
As  the  posterior  border  of  the  bursa  is  firmly 
adherent  to  the  bone,  it  is  necessary  to  infiltrate 
the  deeper  tissues  thoroughly  in  order  to  interrupt 
conduction  in  all  nerves  entering  the  periosteum. 

If  it  is  desired  to  anaesthetize  large  areas  of 
skin,  e.g.  for  the  removal  of  skin  grafts  {ThierscJis 
method),  the  following  procedure  advocated  by 
Braun  may  be  adopted  : 

As  the  nerves  of  the  upper  arm,  in  part  at  any 
rate,  only  pass  through  the  fascia  immediately 
before  their  terminal  ramification,  a  simple  injec- 
tion around  the  area  of  operation  is  not,  in  the 
case,  at  least,  of  the  more  extensive  areas,  sufficient. 
The  operator  therefore  marks  on  the  outer  aspect 
of  the  arm  eight  or  ten  injection  points  about 
2j  centimetres  distant  from  each  other,  and 
from  these  infiltrates  the  subcutaneous  cellular 
tissue  backwards  and  forwards  in  slanting  lines. 
The  solution  is  then  distributed  by  gentle  massage 
movements.  A  0*5  per  cent,  novocain  solution 
with  a  small  addition  of  suprarenin  is  the  most 
suitable,  and  is  to  be  preferred  to  the  cooling  by 
ether  spray  recommended  by  Braun.  If  more 
than  100  c.c.  of  solution  are  required,  the  further 
infiltration,  if  the  operator  hesitates  to  use  more 
of  this  solution,  should  be  made  with  one  of  '25 
per  cent,  strength. 


160  LOCAL  ANESTHESIA 

Schleich's  method  of  endermal  infiltration 
appears  quite  unsuited  for  this  operation,  apart 
altogether  from  its  complexity,  as  it  is  here 
especially  necessary  to  avoid  any  treatment  likely 
to  injure  the  tissues. 

The  anatomical  distribution  of  the  nerves 
above  described  is  to  be  borne  in  mind  also  in 
the  case  of  other  operations,  especially  those  on 
tumours  of  considerable  size.  Where  the  area  of 
operation  is  extensive  it  is  always  necessary  to 
inject  beneath  as  well  as  around  it.  In  the 
forearm,  it  is  true,  most  of  the  nerves  run 
subcutaneously  for  considerable  distances ;  the 
only  exit  of  a  larger  nerve  through  the  fascia 
being  that  of  the  superficial  radial  nerve.  For 
the  majority  of  operations,  therefore,  an  oblique, 
circular,  or  semicircular  injection  will  suffice. 
Variations  in  the  course  of  the  nerve  are,  however, 
sufficiently  frequent  to  indicate  the  method  of 
injecting  beneath  as  well  as  around  the  operation 
area  as  the  one  to  be  generally  employed. 

Of  major  operations,  amputation  of  the  forearm 
especially  has  been  frequently  performed  under 
Schleich's  infiltration  anaesthesia.  Each  layer  of 
tissues  must  here  be  separately  infiltrated.  In 
view  of  the  large  quantity  of  solution  required,  it 
is  best  to  employ  a  '25  per  cent,  novocain  solution. 
Nerve-trunks  must  be  treated  with  special 
thoroughness.     After  division  of  all  soft  parts,  a 


OPERATIONS  ON  THE  EXTREMITIES         161 

very  free  subperiosteal  infiltration  is  necessary. 
Schleich  has  performed  amputations  of  the  fore- 
arm and  leg  under  this  method. 

In  general,  however,  this  method  may,  in  such 
operations,  be  replaced  by  Bier's  venous  anaesthesia, 
which  is  applicable  to  operative  procedures  up  to 
the  junction  between  the  lower  and  middle  thirds 
of  the  upper  arm.  In  practice  it  would  find  most 
frequent  and  suitable  application  in  resections  of 
the  elbow  and  in  operations  on  large  osteomyelitic 
foci.  Anaesthesia  comes  on  sooner  in  the  arm 
than  in  the  leg,  on  account  of  the  smaller  calibre 
of  the  former.  The  indirect  anaesthesia  also 
generally  comes  on  in  a  few  minutes.  Fifty  c.c. 
of  solution  will  always  suffice.  The  anatomical 
relations  of  the  veins  and  the  method  of  finding 
them  are  described  above  (p.  89,  Figs.  5-9). 
Direct  anaesthesia  is  indicated  for  elbow  resections 
and  operations  on  the  arm.  For  operations  on 
the  forearm  Bier  prefers  the  indirect  anaesthesia 
on  account  of  the  difficulty  sometimes  observed  in 
carrying  out  the  injection  owing  to  the  presence 
of  the  valves  in  the  veins. 

For  successful  anaesthetization  of  the  fingers 
and  hands,  it  is  of  the  greatest  importance  in 
the  first  place  to  understand  the  course  of  the 
sensory  nerves  supplying  the  fingers.  Id 
practice  the  chief  point  to  bear  in  mind  is 
that  two  pairs  of  nerves,  a  radial  and  an  ulnar, 

11 


162 


LOCAL  ANAESTHESIA 


a  dorsal  and  a  volar  nerve,  run  fairly  close  to  the 
bone  {vide  Fig.  17).  On  this  fact  is  founded 
the  so-called  Oberst's  method  of  interruption  of 
conduction  in  the  nerve-trunks  at  the  base  of  the 
fingers,  which,  with  Coming's  experiments,  con- 
stitutes the  foundation  for  the  whole  theory  and 
method  of  anaesthesia  by  interruption  of  con- 
duction. Oberst  used  an  elastic  ring,  slipped 
over  the  finger  as  a  tourniquet.  Later,  a  thin 
rubber   band   was  w^ound  round  the  base  of  the 


Fig.  17. — Course  of  Nerves  supplying  the  Fingers. 


finger,  the  ends  being  crossed  over  the  back  of 
the  hand,  carried  round  the  wrist,  and  either  tied 
in  a  knot  or  held  together  by  forceps. 

The  use  of  suprarenin  preparations  in  operations 
on  the  fingers  has  rendered  these  methods  of 
cutting  ofi'the  blood-stream  more  or  less  unneces- 
sary. It  is,  however,  advisable,  especially  in 
operations  on  the  base  of  the  fingers  or  at  a  still 
more  central  point,  to  slow  down  the  blood -stream 
considerably.  In  such  operations,  therefore,  we 
apply  (not  tightly,  so  that  little  or  no  pain  is 
caused)  a  rubber  band  round  the  lower  third  of 


OPERATIONS  OX  THE  EXTREMITIES  163 

the  forearm,  and  then  inject  1  per  cent,  novocain 
solution,  either  without  or  with  only  a  very  small 
addition  of  suprarenin.  If,  on  the  other  hand,  no 
constricting  band  is  applied  at  all.,  it  is  advisable 
to  use  2  per  cent,  novocain  solution  +  suprarenin 
(1  to  2  minims  per  c.c). 

In  operations  on  the  palm  of  the  hand.  1  per 
cent,  novocain  solution  is  employed.  It  is  not 
necessary  in  finger  operations  to  inject  always  at 
the  base  of  the  finger.  The  only  essential  point 
is  that  the  injection  be  made  in  healthy  tissues. 
Thus,  in  operations  about  the  nail  we  may  inject 
at  the  level  of  the  last  phalangeal  joint,  and  only 
a  small  quantity  of  solution  need  be  used.  If  the 
area  of  operation  be  Cjuite  peripheral.  1  per  cent. 
solution  will  be  found  effective  without  tourniquet, 
in  view  of  the  minimal  calibre  of  the  nerve- 
branches  in  the  afiectecl  area. 

The  following  technic[ue  of  injection  has  given 
me  satisfactory  results  {vide  Fig.  IS)  :  At  the 
base  of  the  finger  and  a  little  to  each  side  of  the 
middle  line  of  the  dorsum  an  injection  point  is 
marked  (ethyl  chloride  or  wheal  anaesthesia). 
From  these  points  the  injection  is  made.  Say  we 
commence  at  the  radial  [)oint.  The  needle  is 
introduced  and  passed  a  little  way  towards  the 
volar  .surface,  \  c.c.  of  solution  being  injected  in 
the  neighbourhood  of  the  dorsal  radial  nerves. 
The  needle  is  then  pushed  on  fauly  close  to  the 


dorsal 


164  LOCAL  ANAESTHESIA 

bone,  and  another^  c.c.  injected  in  the  neighbour- 
hood of  the  volar  nerves.  The  same  proceeding 
is  carried  out  on  the  ulnar  side.  Anaesthesia  comes 
on  from  five  to  ten  minutes  after  the  injection. 
Any  operation,  either  on  the  soft  parts  or  on  the 
bones,  can  then  be  painlessly  carried  out.  The 
operation  must  not  be  begun  until  the  finger-tip 
is    quite  insensitive.       In    small    superficial    foci, 

especially  on  the  dorsal  sur- 
face, it  is  often  sufficient  to 
infiltrate  a  strip  on  the  cen- 
tral side  of  the  operation  area. 
One  must  always,  however, 
reckon  with  irregularities  of 
the  nerve-supply,  or  anasto- 
'voiar  moses,  so  that  it  is  generally 
advisable,    in  order  to    feel 

Fig.  18.— Injection  of     quite  safe,   to   inject   a  little 

THE  Finger.  solution  around  the  afi^ected 

area.  It  is  not  generally  necessary  to  inject 
beneath  it. 

In  operations  on  the  base  of  the  fingers  and  up 
to  the  metacarpo-phalangeal  joint  the  injection  is 
carried  out  on  either  side  of  the  metacarpal  bone 
{mutatis  mutandis),  as  described  above  for  the 
peripheral  portion  of  the  digit,  care  being  taken 
that  the  injection  is  made  at  a  sufficient  distance 
from  the  diseased  area.  In  these  cases,  however, 
rather    more    than    2    c.c.    of  solution    must    be 


OPERATIONS  ON  THE  EXTREMITIES  165 

employed.  In  view  also  of  lateral  anastomoses, 
supplementary  subcutaneous  injections  must  be 
made  at  the  sides  with  more  dilute  (1  per  cent.) 
solution. 

As  regards  operations  on  the  hand,  it  is  impor- 
tant to  bear  in  mind  the  point  of  exit  of  the  median 
nerve  at  the  ulnar  border  of  the  ball  of  the  thumb. 

In  operations  about  this  region  this  point  must 
be  freely  infiltrated.  In  general  there  are  so 
many  anastomoses  among  the  nerves  of  the  hand, 
both  lateral  and  also  between  dorsal  and  volar 
nerves,  that  nothing^  can  be  done  by  interruption  of 
conduction  in  single  nerve-trunks. 

On  the  dorsum  of  the  hand  the  ansesthetizationof 
any  superficial  operation  area  presents  no  difficulty. 
If  the  affected  area  be  small,  injection  around  it  is 
sufficient ;  if  larger,  it  will  be  necessary  to  inject 
beneath  it  also.  Of  course,  if  the  operation  be  at 
the  periphery,  the  form  of  the  injection  must  be 
semicircular  or  wedge-shaped,  instead  of  circular, 
and  with  the  base  toward  the  periphery. 

Operations  on  the  periphery  of  the  palm  give 
favourable  opportunity  for  anaesthesia  by  semi- 
circular injection.  Novocain  solution  (1  percent.) 
and  suprarenin  should  always  be  employed.  It  is 
often  advisable,  especially  if  the  operative  pro- 
cedure is  somewhat  complicated,  to  apply  a  rubber 
band,  not  too  tightly,  round  the  forearm.  Up  to 
about  the   middle   of  the   palm   (reckoning   from 


166  LOCAL  ANESTHESIA 

the  periphery),  operations  on  the  deeper  tissues 
(tenotomy)  may  also  be  performed  in  this  manner. 
Where  possible,  the  injection  points  should,  in 
view  of  the  sensitiveness  of  the  skin  of  the  palm, 
be  in  the  interdigital  spaces.  In  the  central  half 
of  the  palm  only  superficial  foci  should  be  attacked 
by  the  simple  method  of  injection  around  and 
beneath  the  affected  area. 

Dupuytren's  contracture  may  be  operated  on 
in  this  way  if  a  thorough  injection  is  made  beneath 
the  parts  to  be  removed.  The  thumb  and  the 
ball  of  the  thumb  may  also  be  cut  off  from  their 
sensory  supply  by  this  method,  a  free  and  deep 
injection  being  made  at  the  ulnar  border  of  the 
thenar  eminence. 

Braun  has  recommended  for  larger  operations 
on  the  hand  a  method  of  interruption  of  con- 
duction in  the  three  main  nerve-trunks — ulnar, 
radial,  and  median — above  the  wrist.  The 
technique  is  not  altogether  simple,  nor  are  the 
results,  in  my  experience,  quite  certain.  The 
method  (Fig.  19)  will,  perhaps,  in  the  future  be 
superseded  by  Bier's  venous  method. 

The  procedure  is  as  follows  :  Two  per  cent, 
novocain  solution  is  employed  +  1  minim  of  supra- 
renin  per  cubic  centimetre.  Of  this  solution  1  c.c. 
is  required  for  each  nerve. 

Injection  for  the  median  nerve :  Above  the 
wrist,  at  the  ulnar  side  of  the  M.  palmaris  longus. 


OPEEATIONS  ON  THE  EXTREMITIES 


167 


The  needle  is  passed  beneath  the  muscle  and  pushed 
onwards  for  a  distance  of  about  1|-  centimetres. 

For  the  ulnar  nerve :  Three  finger-breadths 
above  the  wrist,  between  the  ulna  and  the  tendon 
of  the  M.  flexor  carpi  ulnaris,  the  needle  to  be 
passed  under  the  tendon  and  inserted  altogether 
about  2  centimetres.  A  circular  injection  ( 1  or  '5  per 


N.mterosseus  dors. 


Mulnaris  • 


N.radia^is 


M.  flexor  uheti^ 


A.radialis 


\     M  flexor  radialis 
\JVmecliamis 
M.palm.lonff. 


Fig.  19. — Anesthesia  of  the  Whole  Hand  by  Interrup- 
tion OF  Conduction  (after  Braun). 


cent,  solution)  round  the  forearm  immediately  above 
or  below  the  capitulum  ulnae  should  supplement 
the  foregoing,  and  this  suffices  for  the  radial  nerve. 
For  the  region  supplied  by  the  median  especially 
the  method  is  not  very  trustworthy. 

Finally,  a  few  words  may  be  said  in  connection 
with  phlegmonous  conditions,  especially  phlegmon 
of  the  sheaths  of  the  tendons. 


168  LOCAL  ANESTHESIA 

In  the  first  place,  the  surgeon  cannot  be  too 
strongly  warned  against  the  use  of  ethyl  chloride, 
except  in  the  case  of  quite  small  cutaneous  or 
subcutaneous  foci.  Those  who  have  much  to  do 
with  the  treatment  of  phlegmonous  processes  see, 
far  too  often,  cases  of  suppuration  in  the  sheaths 
of  tendons  in  which  a  small  superficial  incision  has 
been  previously  made  under  cold,  though  any 
accurate  differentiation  of  tissues  is,  under  such 
conditions,  quite  impossible.  The  pain  ceases  or 
diminishes  because  a  small  amount  of  pus  is 
evacuated ;  the  suppurative  process,  however, 
continues,  and  spreads  deeper  and  deeper.  Anaes- 
thesia by  interruption  of  conduction,  too,  is  only 
suitable  for  small  and  easily  demarcated  phlegmons. 
The  more  severe  forms  are  not  suitable  for  local 
anaesthesia  at  all.  It  is  often  quite  impossible  to 
say  before  operation  how  far  such  phlegmons 
extend,  and  it  is  always  to  be  remembered  that, 
apart  from  the  obviously  inflamed  lymphatics  of 
the  arm  or  forearm,  there  are  often  microscopic 
bacterial  infiltrations,  in  the  neighbourhood  of  the 
phlegmonous  focus,  which  involve  serious  risk  of 
spreading  infection  by  an  injection  made  in 
apparently  sound  tissues.  Thus,  I  once  saw  a 
fairly  extensive  necrosis  of  the  subcutaneous  fatty 
tissue  follow  injection  around  and  incision  of  a 
so-called  interdigital  phlegmon — a  complication 
which,  though  it  was  fortunately  recovered  from 


OPERATIONS  ON  THE  EXTREMITIES         169 

without  bad  effects,  caused  an  inconvenient 
delay  in  recovery.  As  I  have  never,  with  this 
exception,  seen  any  occurrence  of  the  kind,  I  feel 
justified  in  assuming  that  infectious  material  was 
disseminated  by  the  injection  among  apparently 
healthy  tissues.  In  the  palm,  especially,  morbid 
processes  affecting  the  deeper  tissues  are,  in  con- 
sequence of  the  tightness  of  the  skin  in  this 
region,  but  very  little  apparent  on  the  surface. 
To  what  extent  Bier's  venous  anaesthesia  will 
supply  us  here  with  a  thoroughly  safe  substitute 
it  is  at  present  impossible  to  say.  In  Bier's  paper 
the  question  whether  lymphangitic  cords  along 
the  arm  are  to  be  regarded  as  contra- indicating  his 
method  is  not  alluded  to.  Even,  however,  if  no 
superficial  inflamed  lymphatics  are  visible,  there 
is  always  a  possibility  that  the  deeper  lymph 
channels  may  be  full  of  infectious  micro-organisms. 
Whether  this  does  or  does  not  constitute  a  danger 
only  further  exjjerience  will  show. 

As  regards  the  lower  extremity  the  older 
methods  of  local  anaesthesia  do  not  suflice  for  any 
but  quite  superficial  operations  on  the  thigh.  For 
Thiersch's  skin-grafting  the  same  rules  apply  as  in 
the  upper  arm.  It  is,  however,  advisable  to  note 
the  amount  of  fatty  tissue,  and  if  the  layer  of  fat 
be  well  marked,  to  infiltrate  very  freely,  a  point, 
indeed,  to  which  attention  should  be  paid  in  all 
operations  on  this  region. 


170  LOCAL  ANESTHESIA 

Operations  on  the  femoral  and  inguinal  glands 
are  only  suitable  for  local  anaesthesia  when  the 
aifected  glands  are  easily  separable  from  the  sub- 
jacent tissues.  Even  then  free  injection  around 
and  especially  underneath  the  area  of  operation 
with  1  per  cent,  novocain-suprarenin  solution  is 
necessary  in  order  to  secure  trustworthy  anaes- 
thesia. As  regards  incision  of  glandular  abscesses, 
what  has  been  stated  above  concerning  parulis 
and  abscesses  in  cervical  glands  applies  here  also. 
Where  the  glandular  tumour  has  been  adherent 
to  the  subjacent  tissues  I  have  seldom  attained  a 
thoroughly  successful  anaesthesia,  even  when,  after 
a  superficial  injection,  a  free  infiltration  after 
Schleich's  method  has  been  carried  out  during  the 
operation. 

For  the  extirpation  of  a  portion  of  the  saphenous 
vein  the  procedure  is  similar  to  that  given  for  pro- 
ducing anaesthesia  of  bone — injection  around  and 
beneath  the  vein  after  the  latter  has  been  made 
clearly  visible  by  obstruction  to  the  flow  of  blood 
within  it. 

With  the  help  of  venous  anaesthesia  surgeons 
have  now  succeeded  in  carrying  out  painlessly 
major  operations  on  the  thigh — indeed,  anaesthesia 
of  the  whole  lower  half  of  the  thigh  has  been  pro- 
duced. Bier  has  carried  out  three  necrotomies  in 
this  way.  He,  however,  regards  it  as  doubtful 
whether  the  present  technique  will  prove  definitely 


OPERATIONS  ON  THE  EXTREMITIES  171 

effective,  as  the  anaesthesia  on  the  outer  side  of 
the  thighj  where  operations  of  this  kind  have,  for 
the  most  part,  to  be  performed,  is  the  latest  and 
most  uncertain  in  its  onset,  because  the  solution  is 
injected  on  the  inner  side. 

Of  operations  on  the  neighbourhood  of  the  knee- 
joint,  those  on  the  bursa  patellae  offer  the  most 
frequent  opportunities  for  the  employment  of  local 
anaesthesia.  Just  as  in  the  case  of  the  bursa 
olecrani,  it  is  possible  here  to  bring  about  a 
reliable  anaesthesia  by  injecting  with  1  or  '5,  per 
cent,  novocain  solution  +  suprarenin,  provided  an 
injection  is  first  made  as  deeply  as  possible  around 
the  bone  and  followed  by  a  circular  subcutaneous 
injection.  Removal  of  loose  bodies  from  the  joint 
has  frequently  been  performed  successfully  after 
injection  around  the  selected  site  of  incision,  and 
subsequently  very  free  infiltration  of  the  deeper 
parts.  I  am,  of  course,  speaking  only  of  bodies 
easily  to  be  felt  externally.  If  one  is  not  sure  of 
reaching  the  loose  body  by  the  first  incision,  it  is 
suggested  by  Braun  as  preferable  that  the  joint 
shall  be  filled  with  '25  per  cent,  solution,  and  a 
period  of  ten  to  twenty  minutes  be  allowed  for  it 
to  act. 

Similarly,  in  other  small  operations  on  the  knee- 
joint  (injection  of  irritant  fluids,  incision  in  cases  of 
suppuration,  with  a  view  to  drainage),  the  synovial 
membrane  must  first  be  rendered  insensitive  by 


172  LOCAL  ANAESTHESIA 

injection  of  an  anaesthetic  solution,  preferably 
'25  to  '5  per  cent,  novocain  solution +  2  minims 
of  suprarenin  per  10  c.c.  An  incision  can  then  be 
made  painlessly,  either  under  circular  anaesthesia 
or  under  Schleich's  infiltration  method.  Of  major 
operations,  Bier  has  performed  several  resections 
of  the  knee-joint  under  direct  venous  anaesthesia. 
The  upper  band  must  not  be  applied  too  close  to 
the  joint. 

In  the  leg,  apart  from  operations  on  superficial 
foci,  all  operations  on  the  anterior  surface  of  the 
tibia  may  be  carried  out  satisfactorily  under 
circular  anaesthesia,  as  above  described. 

Amputations  of  the  leg  have  been  performed  by 
Schleich  and  Reclus  under  infiltration  anaesthesia. 

Tenotomy  of  the  tendo  Achillis  can  be  peformed 
painlessly  after  injection  around  and  beneath  the 
tendon. 

Braun  suggests  the  following  procedure  for  pro- 
ducing anaesthesia  of  the  whole  foot : 

Infiltration  of  the  subcutaneous  cellular  tissue 
all  round  the  limb  above  the  ankle  with  '5  per 
cent,  novocain  solution.  The  same  solution  is 
injected  beneath  the  fascia  at  the  anterior  surface 
of  the  tibia,  in  the  space  between  the  tibia  and 
fibula  and  behind  the  tendo  Achillis ;  finally, 
4  c.c.  of  2  per  cent,  solution  are  employed  to  inter- 
rupt conduction  in  the  tibial  nerve.  Just  above 
the  ankle-joint,  where  the  inner  malleolus  is  at  its 


OPERATIONS  ON  THE  EXTREMITIES  173 

thickest,  the  needle  is  inserted  1  centimetre  inter- 
nally to  the  mesial  border  of  the  Achilles  tendon,  and 
passed  straight  forward  until  it  meets  the  bone.  It 
is  then  slightly  withdrawn,  and  the  injection  made. 
Whether  or  not  the  method  is  to  be  depended  on 
only  further  experience  can  show. 

For  major  operations  on  the  leg  and  foot  Bier 
uses  indirect  instead  of  direct  venous  anaesthesia 
in  all  cases  where  he  wishes  not  to  be  limited  in 
regard  to  the  extent  of  the  operation  area,  also 
when  the  site  of  operation  is  covered  with 
cicatrices,  as,  under  the  latter  conditions,  the  vein 
is  difficult  to  find,  and  the  anaesthesia  is  apt  to  be 
incomplete.  The  operator  must  wait  till  motor 
paralysis  sets  in — i.e.,  generally  about  fifteen 
minutes.  Of  course,  all  other  operations  on  the 
leg  and  foot  can  also  be  carried  out  under  indirect 
anaesthesia. 

Direct  venous  anaesthesia  has  the  advantage 
that  the  operation  can  be  begun  almost  at  once. 
The  saphenous  vein  is  easily  found  anywhere  in 
the  leg  {vide  Figs.  5  and  6).  In  operations  on  the 
foot  Bier  recommends  that  a  rubber  bandage  shall 
be  applied  to  the  most  peripheral  parts.  If  long 
incisions  are  necessary,  the  operation,  may  be 
carried  out  partly  under  direct  and  partly  under 
indirect  anaesthesia.  The  central  tourniquet 
should  be  applied  just  above  the  knee,  the  peri- 
pheral a  little  above  the  middle  of  the  leg.     After 


174  LOCAL  ANESTHESIA 

indirect  anaesthesia  has  set  in  the  peripheral 
tourniquet  is  removed. 

What  has  been  said  above  concerning  the 
upper  extremity  holds  good  also  for  small  opera- 
tions on  the  foot  and  toes  (small  phlegmons, 
exarticulations,  etc.).  Here,  as  there,  a  tourniquet 
may  be  applied  to  the  lower  third  of  the  leg  in 
order  to  deepen  the  anaesthesia. 

The  operation  for  ingrowing  toe-nail  can,  as 
already  stated,  be  performed  satisfactorily  under 
ethyl  chloride  spray,  if  the  nail  be  thoroughly 
frozen  and  the  operation  quickly  carried  out. 

For  operations  in  the  neighbourhood  of  the  first 
metacarpo-phalangeal  articulation  the  middle  of 
the  metacarpal  bone  is  freely  bathed  in  1  per  cent, 
novocain  solution,  the  needle  being  entered  at  the 
dorsum.  The  next  step  is  to  infiltrate  the  tissues 
bordering  the  bone  on  its  outer  side,  carrying  the 
infiltration  up  to  the  interdigital  fold  between  the 
first  and  second  toes.  Anaesthesia  is  more  easily 
and  more  surely  produced  in  the  dorsum  of  the 
foot  than  in  the  sole. 


CHAPTER  XII 
ABDOMINAL  OPERATIONS 

The  degree  of  sensibility  to  paiu  possessed  by  the 
abdominal  organs  has  been  a  much  disputed  point. 
It  might,  indeed,  be  supposed  that  the  large 
number  of  operations  which  have  been  carried  out 
under  anaesthesia  produced  by  infiltration  of  the 
abdominal  wall  must  by  now  have  thoroughly 
cleared  up  the  matter.  That  this  is  by  no  means 
the  case  we  may  ascribe  to  the  fact  that  the 
abdominal  organs  exhibit  an  extraordinary 
variability  in  this  respect.  Thus,  apart  from  the 
fact  that  there  are  unusually  marked  diiferences 
between  individuals,  the  age  of  the  patient,  the 
pathological  condition  of  the  organs,  and  the 
temperature,  are  important  factors,  and  may  help 
to  explain  the  wide  differences  between  the  views 
put  forward  by  different  observers.  According  to 
Lennander,  to  whom  we  owe  the  most  detailed 
investigations  of  the  matter  that  have  yet  been 
made,  all  parts  supplied  by  the  sympathetic  are 
Insensitive,  sensibility  to  pain  being  a  function 
confined  to  the  cerebro-sj)inal  nerves.     According 

175 


176  LOCAL  ANESTHESIA 

to  Emitter,  sensibility  to  pain  is  associated  with  the 
bloodvessels.  His  experiments  on  dogs  (which 
have,  of  course,  less  inferential  value  than  observa- 
tions on  the  human  subject)  revealed,  in  all  the 
organs  of  the  abdominal  cavity,  a  sensibility  to 
pain  whose  intensity  depended  on  the  richness  of 
the  part  in  bloodvessels. 

The  facts  of  chief  practical  importance  may  be 
here  briefly  stated : 

1 .  The  parietal  peritoneum  is  certainly  sensitive 
to  pain,  and  often  the  mesentery. 

2.  The  stomach,  intestine,  omentum,  liver,  renal 
parenchyma,  and  fundus  uteri,  are  insensitive. 

3.  Inflammatory  processes  generally  heighten 
insensibility,  and  this  is  specially  the  case  in  the 
parietal  peritoneum. 

4.  In  the  old,  sensibility  is  generally  diminished. 

5.  Heduction  of  temperature  lowers  sensibility. 

6.  There  are  marked  individual  differences  in 
sensibility,  of  which  we  can  at  present  give  no 
explanation. 

In  regard  to  the  question  whether  any  given 
operation  is  one  for  which  it  is  suitable  to  employ 
local  anaesthesia,  the  following  points  deserve 
attention. 

It  may  be  laid  down  as  a  fundamental  principle, 
that  only  such  operations  should  be  performed 
under  local  anaesthesia  as  can  be  carried  out  pain- 
lessly   to    the    end.     I    do    not  consider  it   good 


ABDOMINAL  OPERATIONS  177 

practice  to  make  a  routine  use,  as  Schleich  does, 
of  the  combined  method — i.e.,  the  employment  of 
general  anaesthesia  for  the  more  painful  parts  of 
an  operation  which  is  otherwise  carried  out  under 
local  anaesthesia.  The  patient  has,  in  the  present 
state  of  the  technique  of  anaesthesia,  the  right  to 
be  operated  on  painlessly,  and  the  risks  of  general 
anaesthesia,  which  are  really  not  great  when  all  is 
taken  into  coDsideration,  should  not  be  unduly 
exaggerated.  There  are,  of  course,  exceptional 
cases  in  which  the  patient's  condition  is  such  that 
no  unnecessary  drop  of  chloroform  or  ether  must 
be  used.  Often,  however,  even  in  such  patients 
a  rapid  narcosis  in  the  course  of  the  operation 
requires  as  much  of  the  anaesthetic  as  would 
suffice  for  the  whole  operation  had  chloroform 
or  ether  been  employed  with  care  and  skill 
throughout.  One  may,  of  course,  be  forced  by 
unforeseen  emergencies  to  call  general  anaesthesia 
to  one's  aid.  Thus  in  case  of  incarcerated  hernia 
in  which  we  are  anxious,  on  account  of  pro- 
nounced cardiac  weakness,  to  operate  under  local 
anaesthesia,  the  existence  of  tough  adhesions  may 
oblige  us  to  continue  the  operation  under  narcosis. 
So,  too,  in  gastrostomy,  which  is  often  performed 
under  local  anaesthesia,  the  stomach  may  be  so 
contracted  that  the  necessary  pull  upon  it  will 
cause  pain.  In  such  case,  very  frequently,  before 
deciding  to   continue  under  general   anaesthesia, 

12 


178  LOCAL  ANAESTHESIA 

the  surgeon  makes  trial  once,  or  perhaps  several 
times,  whether  he  cannot  get  through  without 
chloroform,  and  so  causes  the  patient,  who  has 
probably  received  an  emphatic  promise  of  a  pain- 
less operation,  unnecessary  sutfering. 

Such  contrtftrnps  should  be  avoided,  if  possible, 
and  unless  it  is  absolutelv  necessarv  to  avoid 
general  anaesthesia,  doubtful  operations  of  the 
kind  should  be  performed  throughout  under  ether 
or  chloroform.  The  combination  of  local  anaes- 
thesia with  morphine-scopolamine  narcosis  should 
also  be  unhesitatingly  rejected.  I  have  seen  a 
number  of  cases  in  which  serious  sequelte  mani- 
fested themselves,  and  the  number  of  suro-eons 
who  have  definitely  abandoned  the  method  in- 
creases steadily. 

It  follows,  from  what  has  been  said,  that  it  is 
only  a  comparatively  small  proportion  of  abdo- 
minal operations  that  we  can  perform  under  local 
anaesthesia,  those,  namely,  in  which,  after  the 
abdominal  incision,  the  further  operative  pro- 
cedures are  confined  to  certain  presenting  organs 
(intestine,  omentum)  and  no  dragging  or  pulling 
manipulations  of  any  kind  are  required.  In  some 
individuals,  it  is  true,  especially  some  old  patients, 
it  is  possible  to  carry  out  manipulations  in  the 
abdominal  cavity  freely,  and,  without  any  special 
precautions,  to  pull  on  the  mesentery,  and  so  on. 
Such  cases  are,  however,  exceptional.     It  is  more 


ABDOMINAL  OPERATIONS  179 

usual  to  find  that  the  mere  insertion  of  a  com- 
press between  the  parietal  peritoneum  and  the 
intestinal  coils  is  painful,  and  that  any  vigorous 
traction  on  the  sides  of  the  wound  with  retractors 
is  generally  (probably  because  of  the  dragging  on 
the  parietal  peritoneum  caused  thereby)  found  by 
the  patient  extremely  unpleasant. 

Schleich  infiltrates  the  abdominal  organs,  as  he 
does  other  tissues,  to  the  point  of  oedema.  Those 
who  hold,  as  most  surgeons  do,  that  in  abdominal 
surgery  the  organs  must  be  handled  as  gently  as 
possible,  can  hardly  approve  of  this  procedure. 
One  can,  of  course,  infiltrate  the  pedicle  of  an 
ovarian  tumour,  or  the  line  of  incision  in  a  gall- 
bladder which  is  to  be  opened,  but  operations  on 
the  ovaries  or  the  gall-bladder  involve  other 
manipulations,  such  as  the  drawing  forward  of  the 
ovarian  tumour  and  the  indispensable  sounding  of 
the  gall-ducts,  which  are  painful,  and  in  which 
infiltration  is  of  little  use. 

Infiltration  of  the  wall  of  the  stomach  for  the 
purpose  of  a  gastrostomy  involves,  in  my  opinion, 
risk  of  injury  to  the  tissues  infiltrated,  and  this  is 
altogether  apart  from  the  facts  that  the  stomach 
is  itself  insensitive,  that  only  the  act  of  dragging 
on  it  is  painful,  and  that  against  this  pain  local 
anaesthesia  leaves  us  powerless. 

Local  anaesthesia,  then,  in  abdominal  operations, 
can  do  little   more  than  render  painless  the  in- 


180  LOCAL  ANESTHESIA 

cision  in  the  abdominal  wall.  The  method  now 
usually  employed  is  a  modified  form  of  Schleich's 
infiltration  anaesthesia — that  is  to  say,  an  infiltra- 
tion of  the  parts  with  somewhat  concentrated 
solutions,  which,  however,  is  not  carried  to  the 
point  of  causing  a  maximum  degree  of  oedema, 
and  is,  if  possible,  completed  before  the  beginning 
of  the  operation. 

This  method  is  often  combined  with  circular 
anaesthesia  of  particular  regions.  If  only  a  small 
incision  is  required,  and  the  abdominal  wall  is 
thin,  we  may  employ  1  per  cent,  novocain  solution 
+ 1  to  2  minims  of  suprarenin  per  10  c.c.  For 
larger  incisions  '5  or  '25  per  cent,  solution  is 
employed,  according  to  the  quantity  required  for 
the  infiltration.  The  method  is  most  successful 
in  very  thin  subjects,  in  whom,  in  the  case  of  a 
median  incision,  the  whole  infiltration  may  be 
completed  before  the  commencement  of  the  opera- 
tion. The  operator  first  infiltrates  subcutaneously 
to  a  distance  of  a  centimetre  or  two  from  the 
chosen  line  of  incision,  and  follows  this  up  with  a 
free  subfascial  infiltration.  In  about  ten  minutes 
one  can  count  on  complete  anaesthesia.  Only  when 
more  room  is  required  for  the  suture  is  it  neces- 
sary, after  division  of  the  fascia,  to  proceed  to  a 
further  infiltration,  on  both  sides  of  the  incision 
of  the  prseperitoneal  tissue.  The  same  procedure 
may  be  adopted  away  from  the  median  line  in 


ABDOMINAL  OPERATIONS  181 

thin  subjects,  if  the  region  of  operation  is  one  in 
which  the  muscles  and  fasciae  are  very  thin,  as,  for 
example,  in  the  formation  of  an  artificial  anus,  and 
often  also  in  gastrostomy. 

The  larger  the  quantity  of  fat  in  the  abdominal 
wall,  the  more  difficult  is  the  ansesthetization,  at 
any  rate  in  patients  whose  abdominal  wall  is  at 
all  tense.  It  is  then  often  necessary  to  anaes- 
thetize the  skin  itself  by  the  wheal  method  over 
the  selected  line  of  incision.  Then,  after  infiltration 
of  the  subcutaneous  cellular  tissue,  the  incision 
may  be  carried  down  to  the  fascia.  The  injecting 
needle — a  right-angled  one  is  not  absolutely  neces- 
sary— is  then  passed  under  the  fascia  and  the 
praeperitoneal  tissue  infiltrated,  the  infiltration 
being  continued  farther  after  division  of  the  fascia. 

If  large  nerves  are  met  with  in  the  area  of 
operation,  the  solutions  employed  must  not  be 
too  dilute  (1  per  cent,  novocain  solution).  If  the 
incision  be  a  small  one,  the  infiltration  may  be 
carried  out  to  the  end  without  change  of  solution. 
Here,  too,  in  thin  subjects,  the  whole  or  the  greater 
part  of  the  infiltration  may  be  carried  out  before 
the  operation  is  begun — e.g.,  in  an  incision  at  the 
outer  border  of  the  rectus,  in  which  special  atten- 
tion must  be  paid  to  the  obliquely-running 
branches  of  the  intercostal  nerves,  or  in  a  slanting 
incision  such  as  is  made  in  cases  of  perityphlitis, 
when  the  ilio-hypogastric  and  ilio-inguinal  nerves 


182  LOCAL  ANiESTHESIA 

are  found  running  in  the  deeper  muscular  layers 
between  the  internal  oblique  and  transverse 
muscles. 

In  individuals,  however,  with  a  larger  deposit 
of  fat,  an  infiltration  of  the  separate  layers  step 
by  step  is  required. 

I  will  give  here  the  technique  for  an  incision  in 
the  flank,  as  described  by  Braun,  merely  substi- 
tuting novocain  solution  for  that  of  cocain. 

Wheal  anaesthesia  of  the  skin  along  the  line 
of  incision,  using  -25  per  cent,  novocain  solution 
with  suprarenin.  Infiltration  of  the  subcutaneous 
cellular  tissue  in  the  form  of  a  Hackenbruch's 
rhombus.  Division  of  the  soft  parts  down  to  the 
fascia.  Infiltration  of  and  beneath  the  external 
oblique  muscle  in  the  line  of  incision.  A  short 
period  of  waiting.  Division  of  the  muscle  and  its 
fascia,  followed  by  injection  of  about  3  c.c.  of 
1  per  cent,  solution  in  a  line  along  the  lateral 
border  of  the  divided  external  oblique  (drawn 
outwards  for  the  purpose),  into  the  muscular 
tissue  of  the  internal  oblique  and  transversus  as 
far  in  a  lateral  direction  as  possible.  A  few 
minutes  waiting.  Division  of  both  muscles  in  a 
direction  parallel  to  the  course  of  the  fibres. 
Infiltration  of  the  now  exposed  praeperitoneal 
tissue  with  '25  per  cent,  solution  over  a  wider 
area  around  the  line  of  operation.  Division  of 
the  peritoneum  in  a  diagonal  direction.  , 


ABDOMINAL  OPEEATIONS  183 

The  whole  infiltration  may  be  carried  out  quite 
well  with  '5  per  cent,  solution,  only  remember- 
ing to  infiltrate  specially  freely  the  internal 
oblique  and  transversus  muscles  in  which  the 
nerves  run. 

I  have  endeavoured  to  give  above,  in  outline, 
the  points  necessary  for  a  decision  of  the  question 
whether  local  anaesthesia  shall  be  employed  or  not. 
Individual  peculiarities  must,  of  course,  not  be  left 
out  of  consideration  in  the  matter. 

Of  morbid  processes  in  this  region  we  may 
mention  as  specially  suitable  for  operation  under 
local  anaesthesia  extra-peritoneal  abscesses — e.g.., 
large  encapsuled  perityphilitic  abscesses,  if  so  far 
softened  that  only  a  simple  incision  is  required, 
also  cystic  tumours  which  merely  require  opening 
(hydatid  cysts).  Formation  of  an  artificial  anus 
and  gastrostomy  are  also  suitable  for  local  anaes- 
thesia in  many  cases.  The  latter  operation,  how- 
ever, cannot  be  performed  painlessly  if  there  is 
much  contraction  of  the  organ,  and  this  is  not 
infrequently  the  case. 

Other  simple  laparotomies  which  do  not  involve 
manipulations  in  the  abdominal  cavity  may  also  be 
performed  under  local  anaesthesia. 

Operations  for  appendicitis  are,  in  some  clinics, 
frequently  performed  under  local  anaesthesia ; 
whether  always  painlessly  I  should  not  like  to  say. 
It  is  impossible  to  say  beforehand,  with  the  least 


184  LOCAL  ANESTHESIA 

approach  to  certainty,  whether  or  not  adhesions, 
generally  involving  the  parietal  peritoneum,  are 
present.  Where  they  exist  local  anaesthesia  is 
illusory. 

But  even  in  the  absence  of  adhesions,  the 
simple  fact  that  the  caecum  is  often  fairly  closely 
attached  to  the  posterior  abdominal  wall,  and 
that,  in  consequence,  a  slight  pull  is  required  to 
bring  the  appendix  into  the  wound,  may  be 
sufficient  in  many  cases  to  preclude  all  chance 
of  the  operation  being  performed  under  local 
anaesthesia  without  severe  pain. 

Hernia  Operations. 

It  is  necessary  to  distinguish  between  herni- 
otomy for  strangulated  hernia  and  the  so-called 
radical  operation.  The  first  offers  generally  a 
very  favourable  field  for  the  emj^loyment  of  local 
anaesthesia.  The  reason  for  this  is  not  very  clear. 
We  must  not  attach  any  great  significance  in  this 
matter  to  the  mental  attitude  of  the  j)atient,  who 
is,  of  course,  grateful  for  the  prospect  of  relief 
from  his  suffering,  for  in  the  case  of  pains  in  other 
regions  of  the  body,  far  surpassing  in  intensity 
those  proceeding  from  a  strangulated  hernia,  we 
meet  with  no  such  psychic  analgesia  during  the 
operation.  The  diminution  of  sensibility  to  pain 
noticed  in  strangulated  herniae  must  be  almost 


ABDOMINAL  OPERATIONS  185 

entirely  attributable  to  a  disturbance  of  nutrition 
in  the  nerves  which  pass  through  the  constrict- 
ing ring  to  the  hernial  sac,  which  disturbance  is 
to  be  attributed  partly  to  compression  of  the 
nerves  at  the  point  of  constriction,  and  partly  to  a 
blood  stasis  aifecting  the  w^hole  strangulated  area. 
Where  the  strangulation  has  existed  for  some 
time,  and  especially  in  old  persons,  it  is  often 
only  necessary  to  anaesthetize  for  the  skin  incision 
in  order  to  be  able  to  perform  the  whole  opera- 
tion painlessly.  The  shorter  the  duration  of  the 
strangulation  has  been,  the  less  can  we  count  on 
the  presence  of  this  condition  of  diminished  sensi- 
bility. Where  the  lowering  of  sensibility  is 
marked,  it  often  affects  the  parts  surrounding  the 
constricting  ring  to  such  an  extent  that  it  is 
possible,  in  addition  to  the  herniotomy,  to  per- 
form painlessly  a  radical  operation,  and  this  with 
only  a  slight  injection,  though,  in  the  absence  of 
strangulation,  it  is  not  an  easy  matter  to  perform 
a  radical  operation  under  local  anaesthesia  on,  say, 
an  inguinal  hernia. 

The  hernial  contents  in  a  strangulated  hernia 
cannot  be  directly  anaesthetized  ;  the  breaking- 
down  of  adhesions,  however,  between  the  hernial 
sac  and  its  contents  is  rendered  painless  by 
anaesthetization  of  the  sac.  Dragging  and  pulling 
the  organs  within  the  sac  causes  pain.  The 
larger    the    hernia   the   sooner  will   the   operator 


186  LOCAL  ANESTHESIA 

find  himself  compelled  to  have  recourse  to  such 
manipulations. 

In  umbilical  hernias  the  distribution  of  the 
nerves  involved — converging  radially  from  all 
sides  upon  the  umbilicus — is  a  very  simple  one. 
The  circular  method  is,  therefore,  generally  the 
best  to  employ  here,  the  solution  ("25  to  1  per 
cent,  novocain-suprarenin  solution)  being  injected 
all  round  the  umbilical  ring,  first  under  the  fascia, 
and  then  in  the  subcutaneous  cellular  tissue. 

In  large  irreducible  hernias  with  fatty  abdo- 
minal walls  the  method  is  often  insufiicient. 
Here,  after  a  surrounding  subcutaneous  injection, 
the  hernia  must  be  opened  by  a  curved  incision 
over  its  greatest  circumference  with  the  aid  of 
Schleich's  skin-wheal  anaesthesia,  using  the  fingers 
as  a  director.  The  sac  must  then  be  more  widely 
spread,  and  the  prseperitoneal  tissue  surrounding 
the  neck  of  the  hernial  sac  freely  infiltrated  from 
the  wound. 

Local  ansesthesia  is,  however,  only  of  limited 
applicability  to  operations  on  umbilical  hernias. 
We  have  seen  that  it  is  far  easier  to  carry  out 
a  hernia  operation  under  local  anaesthesia  if  the 
hernia  be  strangulated.  Even  in  strangulated 
cases,  however,  patients  with  tense  abdominal 
walls  often  prove  unsuitable  subjects  for  local 
anaesthesia.  If  the  parts  are  much  stretched  in 
suturing,   local    anaesthesia    is    often    inefiective. 


ABDOMINAL  OPERATIONS  187 

The  best  subjects  are  women  with  lax  abdominal 
walls. 

Often,  too,  a  very  large  hernia,  or  very  strong 
adhesions,  render  a  case  unsuitable  for  local 
anaesthesia.  It  must  not  be  understood  that  it 
always  fails  in  such  cases,  but  rather  that  it 
cannot  be  regarded  as  an  absolutely  certain 
method,  and  should  therefore  only  be  employed 
when  very  strongly  indicated.  Finally,  local 
anaesthesia  must  be  employed  with  great  caution 
in  patients  with  a  large  deposit  of  fat  in  the 
abdominal  wall.  Here  it  is  not  so  much  any 
failure  in  the  anaesthesia  that  is  to  be  feared  as 
the  tendency  of  adipose  tissue  to  necrosis,  for 
even  the  most  unirritating  injection  involves  some 
injury  to  tissue,  if  only  a  minimal  one. 

What  has  been  said  above  concerning  um- 
bilical hernias  applies  also  to  hernia  of  the  linea 
alba. 

In  inguinal  hernias  the  conditions  are  much 
more  compHcated,  seeing  that  in  the  neighbour- 
hood of  the  inguinal  canal  there  are  various  nerve- 
trunks  of  considerable  size  crossing  each  other  in 
different  directions. 

The  figure  given  on  the  next  page  shows  the 
distribution  of  the  separate  nerves.  The  internal 
inguinal  ring,  in  whose  neighbourhood  the  surgeon 
is  bound  to  work  in  performing  a  radical  opera- 
tion, which    is    nowadays    ahuost    always    super- 


188 


LOCAL  ANESTHESIA 


added  to  a  herniotomy,  is  so  situated,  as  the 
figure  shows,  that  conduction  must  be  interrupted 
in    all    the  nerves  in  order  to  render  it  and  its 

neighbourhood  anaes- 
thetic. 

As  a  rule  anaesthe- 
sia is  most  easily  at- 
tained in  cases  where 
the  inguinal  hernia  is 
strangulated.  The 
operator  first  injects 
deeply  around  the 
neck  of  the  hernial 
sac  with  '5  or  1  per 
cent,  novocain  solu- 
tion. The  subcuta- 
neous tissue  is  then 
infiltrated  alono^  the 
selected   line    of    in- 


-DisTRiBUTioN  OF  Nerves  cisiou,  the  skiu  haviug 
Inguinal     or     Crural  t  .        t 

been  previously  anses- 


FiG.    20. 
in     the     inguinal    or 
Eegions  (after  Braun). 

1.    N.    genito-femoralis.      2.    N.    sper-  thotized  by  the  whcal 

maticus     externus.        3.     N".      lumbo-  ™„j.i^    /I  '-P      -j-k  U 

inguinalis.       4.     N.     ilio  -  inguinalis.  metnOQ  II      ine      aO- 

5.    N.    ilio-hypogastricus.      6.    Rami  rlnininnl  wall     i*g  \7(^r\T 

cutaneiant.  N.  intercostalis  xii.  UOmmai  Wail    IS  Very 

fatty.  The  tissues 
are  then  divided  down  to  the  aponeurosis  of  the 
external  oblique  muscle,  the  incision  being  ex- 
tended sufficiently  to  expose  the  neighbourhood 
of  the    external    inguinal   ring.      The  needle    is 


ABDOMINAL  OPERATIONS  189 

then  inserted  through  the  aponeurosis  a  little 
above  the  constricting  ring  and  solution  is 
injected,  at  first  in  a  direction  parallel  to  and 
immediately  above  Poupart's  ligament,  then  at 
a  point  somewhat  above  and  external  to  the 
first,  where  the  internal  oblique  and  transversus 
muscles  pass.  This  will  anaesthetize  the  hernial 
sac  sufficiently  to  allow  of  its  being  opened.  If  it 
is  preferred  not  to  open  the  sac  until  the  neigh- 
bourhood of  the  external  ring  is  completely  ex- 
posed, it  is  necessary  either  to  wait  or  to  divide 
under  continuous  infiltration,  first  the  aponeurosis 
at  the  external  inguinal  ring,  and  then  the  con- 
stricting ring  itself.  There  follow  now  replace- 
ment of  the  contents  of  the  sac,  further  infiltration 
of  the  whole  prseperitoneal  tissue,  ligature  of  the 
hernial  sac,  and  radical  operation. 

For  the  radical  operation  on  free  hernias — I 
have  experience  only  of  Bassini's  method — Cush- 
ing's  method  of  endoneural  injection  of  the 
separate  nerve- trunks  was  formerly  often  em- 
ployed. On  account  of  its  troublesomeness,  how- 
ever, it  never  became  really  popular. 

Meanwhile,  in  consequence  of  our  ability  to 
employ  nowadays  more  concentrated  anaesthetic 
solutions  without  any  risk,  a  method  has  been 
successfully  devised  which  has  been  already 
adopted  by  a  number  of  surgeons  {Braun,  Nast- 
Kolb,  etc.),  and  which  may  be  regarded  as,  to  a 


190 


LOCAL  ANESTHESIA 


certain  extent,  a  successful  outcome  of  the  many 
endeavours  that  have  been  made  to  render  in- 
guinal hernias  operable  under  local  anaesthesia. 
Its  simplicity,  too,  will  probably  materially  con- 
tribute to  secure  its  adoption  in  practice. 


V 


-> 


Fig.  21. — Method  of  Anesthetization  for  the  Eadical 
Operation  on  an  Inguinal  Hernia. 


The  needle  is  first  inserted  (after  formation  of 
a  cutaneous  wheal)  1  centimetre  above  the  end 
of  the  selected  line  of  incision,  and  the  subcu- 
taneous tissue  underneath  and  around  that  line 
IS    infiltrated  with    '5    per  cent,    novocain-supra- 


ABDOMINAL  OPERATIONS  191 

renin  solution.  From  the  same  point  of  injection 
the  fascia  is  penetrated,  and  the  needle  passed 
through  the  whole  thickness  of  the  abdominal 
wall,  infiltrating  the  deeper  tissues,  first  in  a 
median  direction,  then  laterally  towards  Poupart's 
ligament.  The  injecting  needle  is  now  inserted  a 
little  below  the  external  inguinal  ring  (again  after 
formation  of  a  cutaneous  wheal),  the  spermatic 
cord  is  raised  and  injected,  then,  while  the  needle 
is  either  passed  on  through  the  external  inguinal 
canal  or  made  to  penetrate  the  aponeurosis  a  little 
above  the  external  inguinal  ring,  the  operator 
injects,  both  in  a  median  and  a  lateral  direction 
from  the  spermatic  cord,  the  deeper  tissues  of  the 
abdominal  wall.  After  waiting  a  certain  time,  the 
operation  may  be  begun.  From  30  to  50  c.c. 
of  solution  are  usually  employed.  It  is  always 
advisable  to  infiltrate  very  freely. 

In  subjects  with  very  fatty  abdominal  walls  the 
method  is  not  a  very  sure  one.  Unless  there  is 
some  special  ground  for  avoiding  a  general  anaes- 
thetic, operators  who  are  not  thoroughly  practised 
in  local  anaesthetic  methods  had  better  forego  the 
attempt  to  operate  under  local  anaesthesia  in  these 
cases.  If  local  anaesthesia  is  to  be  employed,  the 
separate  layers  must  be  infiltrated  step  by  step 
after  Schleich's  method,  some  waiting  time  being 
allowed  after  each  successive  step  of  the  process, 
and    special    attention    being    paid    to    the    prae- 


192  LOCAL  ANESTHESIA 

peritoneal  tissue.  The  method  cannot  be  regarded 
as  a  perfect  one,  and  though,  as  a  rule,  when 
carried  out  correctly,  it  enables  the  surgeon  to 
operate  painlessly,  vigorous  dragging  on  the 
spermatic  cord,  which  cannot  in  some  cases  be 
avoided,  is  not  always  quite  painless  to  the 
patient.*  What  has  been  said  as  regards 
Bassini's  radical  operation  applies  also  to  the 
Alexander- Adams  operation  in  women. 

In  herniotomy  for  strangulated  femoral  hernia 
the  method  of  circular  injection  is  effective.  The 
injection  is  made,  first  subcutaneously,  then  into 
the  deeper  parts,  special  care  being  given  to  the 
injection  of  the  prseperitoneal  tissue  at  the  neck  of 
the  hernial  sac.  Exposure  and  ligature  of  the  sac 
can  then  be  carried  out  painlessly,  provided  there 
be  not  too  great  a  development  of  fat. 

If  \^  radical  operation  is  to  supplement  the 
herniotomy,  the  parts  to  be  fixed  in  contact,  and 
again  especially  the  prceperitoneal  tissue,  must  be 
freely  infiltrated.  The  infiltration  can  only  be 
carried  out  after  complete  exposure  of  the  fascia, 
owing  to  the  presence  of  the  large  femoral  blood- 
vessels in  this  region. 

*  The  method  failed  in  a  case  of  congenital  hernia  in  an 
adult.  The  failure  will  appear  explicable  on  a  study  of  the 
anatomical  conditions  present  in  such  cases. 


CHAPTEE  XIII 

OPERATIONS  ON  THE  ANAL  EEGION  AND 
GENITO-URINARY  TRACT 

The  mucous  membrane  of  the  urethra  possesses 
a  fairly  high  degree  of  sensibility  to  pain,  which 
is,  however,  more  marked  in  the  posterior  than  in 
the  anterior  portion  of  the  urethral  tube.  The 
vesical  mucosa  is,  in  normal  conditions,  very 
slightly  sensitive,  but  when  inflamed  may  exhibit 
a  high  degree  of  sensibility. 

For  anaesthetizing  the  human  male  urethra, 
with  a  view,  for  instance,  to  the  carrying  out  of  a 
difficult  catheterization  or  of  a  cystoscopy,  we 
have  found  the  following  method  eflective  :  With 
an  ordinary  gonorrhoeal  syringe  of  about  5  c.c. 
capacity,  30  to  .50  c.c.  of  2  per  cent,  novocain 
solution  (the  addition  of  suprarenin  is  not  abso- 
lutely necessary)  are  slowly  injected  into  the 
urethra,  and  their  escape  prevented  by  placing 
round  the  base  of  the  glans  a  rubber  ring  or  a 
piece  of  bandage.  A  certain  amount  of  the 
solution   usually  finds  its  way  into  the  bladder. 

193  13 


194  LOCAL  ANESTHESIA 

The  greater  part,  however,  remains  in  the  dis- 
tended urethra. 

In  ten  minutes  the  solution  may  be  allowed  to 
flow  away,  and  the  catheter  or  cystoscope  can 
then  almost  always  be  introduced  without  causing 
pain. 

If  a  stricture  is  present,  suprarenin  is  freely 
added  to  the  solution,  and  as  much  of  the  latter  as 
the  urethra  will  hold  is  injected.  It  is  left  to  act 
for  at  least  fifteen  minutes  in  order  that  the  supra- 
renin may  exert  its  full  detumefying  effect  on  the 
mucous  membrane.  It  will  then  generally  be 
found  possible  to  pass  a  fine  catheter.  In  the 
subsequent  dilatation  the  same  procedure  is 
adopted ;  the  results,  however,  as  regards  anaes- 
thesia are  not  so  certain. 

According  to  Reclus,  internal  urethrotomy  can 
be  painlessly  performed  after  injection  into  the 
urethra  of  1  per  cent,  cocain  solution.  This 
solution  would  now  be  replaced  by  2  per  cent, 
novocain-suprarenin  solution. 

In  external  urethrotomy  the  urethra  must  first 
be  anaesthetized  in  the  manner  above  described, 
after  which  the  operator  must  inject  all  round  the 
operation  area,  special  care  being  given  to  the 
injection  of  the  deeper  parts. 

It  is  seldom  necessary  to  anaesthetize  the  female 
urethra.  Occasionally  I  have  removed  small 
growths  from  the  neighbourhood  of  the  meatus 


OPEEATIONS  ON  THE  ANAL  EEGION        195 

urinarius  under  circular  anaesthesia.  If  the  whole 
urethral  mucous  membrane  is  to  be  rendered 
insensitive,  it  is  only  necessary  to  dip  a  pledget  of 
cotton- wool  wrapped  round  a  thin  rod  of  some  kind 
in  2  per  cent,  novocain  solution,  and  place  it  in 
the  urethra  for  a  few  minutes. 

The  vesical  mucous  membrane  can  also  be 
rendered  insensitive  without  much  difficulty. 
The  bladder  is  filled,  according  to  its  capacity, 
with  or  without  previous  ansesthetization  of 
the  urethra,  with  '25  to  "5  per  cent,  novocain- 
suprarenin  solution,  which  is  then  left  to  act  for 
at  least  twenty  minutes. 

If  the  vesical  capacity  is  very  small,  Braun 
advises  that  the  operator  should  cautiously  allow 
the  solution  to  flow  in  under  slight  pressure  from 
any  irrigator.  The  vesical  spasm  then  gradually 
gives  way,  so  that  the  bladder,  after  twenty  or 
thirty  minutes,  has  generally  regained  its  full 
normal  capacity.  The  suprapubic  operation 
should  not  be  attempted  under  local  anaesthesia 
save  in  thin  patients  with  very  lax  abdominal 
walls,  in  whom  no  stretching  of  the  muscles  is 
necessary.  The  vesical  mucous  membrane  must 
first  be  anaesthetized,  and  the  site  of  the  abdom- 
inal incision  then  infiltrated  in  the  ordinary  way 
after  Schleich's  method. 

Of  operations  on  the  penis,  that  for  phimosis 
is    one    of  the   most  favourable  of  all  operative 


196  LOCAL  ANESTHESIA 

procedures    for   the   employment   of  local  anaes- 
thesia. 

If  E-oser's  operation  is  to  be  performed,  the 
whole  line  of  incision  should  be  freely  infiltrated 
between  the  inner  and  outer  surfaces  of  the  prepuce 
with  1  per  cent,  novocain  solution.  Further  infil- 
tration should  be  made  during  the  process  of 
incision ;  special  attention  must  be  paid  to  the  in- 
jection at  the  fold  between  the  glans  and  the  inner 
prseputial  surface,  if  the  so-called  lobule  of  Roser 
is  to  be  formed.  If  the  infiltration  be  sufiiciently 
free,  complete  anaesthesia  is  always  attained. 

If,  as  is  now  more  often  the  case,  circumcision 
is  to  be  performed,  this  can  always,  so  far  as  my 
experience  goes,  be  carried  out  successfully  under 
circular  anaesthesia.  The  surgeon  injects  freely 
from  one  or  two  points  all  round  the  organ  at  the 
level  of  the  sulcus  coronarius,  using  for  the  pur- 
pose 1  per  cent,  novocain-suprarenin  solution ; 
then,  after  retraction  of  the  prepuce,  he  infiltrates 
specially  the  very  sensitive  frenulum.  If  the 
prepuce  cannot  be  sufficiently  retracted,  it  must 
be  slightly  incised  after  full  infiltration  of  the  site 
of  incision.  If,  then,  sufficient  time  (about  ten 
minutes)  is  allowed,  the  operation  can  generally 
be  painlessly  performed.  Before  commencing  to 
operate  the  surgeon  should  ascertain  by  means  of 
a  surgical  forceps  whether  the  inner  praeputial 
surface,  which  is  much  more  sensitive  and  more 


OPERATIONS  ON  THE  ANAL  REGION         197 

difficult  to  anaesthetize  than  the  outer,  is  also 
thoroughly  insensitive. 

In  the  operation  for  paraphimosis  the  most 
practical  method  is  to  infiltrate  freely,  after 
Schleich's  method,  the  selected  line  of  incision.  If 
the  deeper  layers  are  also  injected,  further  infiltra- 
tion during  the  operation  is  not  necessary.  If  a 
supplementary  circumcision  is  determined  on,  the 
surgeon  may,  as  recommended  by  Braun,  inject 
round  the  organ  immediately  on  the  proximal  side 
of  the  constricting  ring,  and  then  round  the  line 
between  the  latter  and  the  glans  under  the 
retracted  praeputial  mucous  membrane. 

Reclus  has  performed  amputations  of  the  penis 
under  infiltration  anaesthesia.  The  operation 
should  present  no  difficulties  for  local  anaesthesia 
if  the  penis  be  infiltrated  in  its  whole  circum- 
ference with  1  per  cent,  novocain  solution,  either 
on  the  proximal  side  of  the  line  of  amputation,  or 
at  the  line  itself 

Superficial  operations  on  the  scrotum  may  be 
performed  under  simple  circular  anaesthesia. 

Puncture  of  a  hydrocele  may  be  made  painless 
by  Schleich's  infiltration  of  the  site  of  puncture. 
During  the  infiltration,  as  during  the  puncture 
itself,  the  skin  of  the  scrotum  is  drawn  tightly 
back.  If  an  irritant  fluid  (tincture  of  iodine)  is  to 
be  injected,  the  cavity  must  be  filled,  after  the 
hydrocele  fluid  has  drained  away,  with    '25  per 


198  LOCAL  ANESTHESIA 

cent,  novocain  solution,  and  the  trocar  left  in  situ. 
The  solution  must  be  left  to  act  for  about  fifteen 
minutes,  and  then  allowed  to  flow  away.  The 
irritant  fluid  can  then  be  injected  without  pain. 

For  larger  scrotal  operations,  such  as  operations 
for  hydrocele  or  castrations,  anaesthesia  by  inter- 
ruption of  conduction  is  the  best  method  to 
employ.  Novocain  solution  (1  per  cent.)  with 
suprarenin  should  be  employed.  If  a  greater 
quantity  of  solution  than  usual  is  required,  the 
additional  quantity  should  be  in  '5  per  cent, 
strength. 

The  spermatic  cord  is  first  seized  as  high  as 
possible  between  finger  and  thumb,  pressed  against 
the  tightened  skin,  and  injected  with  several  cubic 
centimetres  of  solution.  Its  surroundings  are  then 
freely  injected.  This  injection  renders  the  testicle 
and  its  coverings  insensitive  in  about  ten  minutes. 
If  the  operation  is  merely  on  a  hydrocele,  a  free 
infiltration  around  the  spermatic  cord  will  suffice, 
the  scrotal  incision  being  then  made  painless  by 
the  circular  method,  or  by  subcutaneous  injection 
beneath  the  line  of  incision. 

In  castration  the  whole  connective  tissue  of  the 
scrotum  must  be  infiltrated  in  a  plane  perpen- 
dicular to  the  spermatic,  and  at  as  high  a  level  as 
possible.  Owing  to  the  great  laxity  of  the  skin, 
two  points  of  injection  generally  suffice,  one  for 
the  injection  into  the  spermatic  cord,  and  another 


OPERATIONS  ON  THE  ANAL  REGION         199 

at  the  posterior  surface  of  the  scrotum  at  the  root 
of  the  cord.  The  ansesthetization  of  these  middle 
parts  often  presents  difficulties  owing  to  the  great 
laxness  of  the  tissues,  which  enables  them  to  take 
up  a  large  quantity  of  solution.  A  free  infiltra- 
tion here  with  '5  per  cent,  solution  is  advisable. 
If  after  fifteen  minutes  this  region  is  not  com- 
pletely anaesthetic,  the  skin  must  be  anaesthetized 
by  the  wheal  method.  The  procedure  is  com- 
pleted by  an  infiltration  of  the  raphe  between  the 
two  testicles.  If  the  technique  is  carefully  and 
correctly  carried  out,  the  surgeon  can  count  on  a 
painless  operation. 

Operations  of  every  kind  on  the  female  ex- 
ternal genital  organs — e.g,  suture  of  ruptured 
perineum,  incision  of  suppurating  glands  of  Bar- 
tholini,  cauterization  of  tumours,  etc. — can  be 
performed  satisfactorily  under  local  anaesthesia. 
Colporrhaphy  also  can  be  very  successfully  per- 
formed under  circular  submucous  injection,  only, 
however,  in  persons  in  whom  distension  of  the 
vaginal  orifice  by  the  speculum  is  borne  without 
pain.  Many  multiparae  suffer  no  pain,  either  from 
the  introduction  or  manipulation  of  specula,  or 
from  traction  on  the  uterus  with  forceps. 

In  such  women  operations  on  the  not  very  sen- 
sitive portio  vaginalis  of  the  cervix  can  be  carried 
out  after  circular  injection  of  a  few  cubic  centi- 
metres of  an  anaesthetic  solution.  Vagina  fixations 


200 


LOCAL  ANESTHESIA 


have  also  been  frequently  performed  lately  under 
local  anaesthesia. 

Operations  on  the  rectum  constitute  one  of  the 
most  important  fields  for  local  anaesthesia.  Bier 
is  quite  right  when  he  pronounces  it  a  mistaken 
practice  to  employ  general  anaesthesia  for  the 
minor  surgery  of  the  anal  region  unless  it  is  for 


Sphincter  anl 
externus 


Fig.  22. — Anesthetization  of  the  Anal  Eegion. 


some  reason  specially  indicated.  Local  anaesthesia 
gives  excellent  results  in  operations  for  fissure 
and  for  haemorrhoids,  and  in  dilatation  of  the 
sphincter  ani.  I  use  the  following  method,  de- 
scribed by  Braun,  for  the  anaesthetization  of  the 
whole  anal  region,  and  find  it  always  effective 
(see  Fig.  22). 

Four   injection  points    are    marked  round   the 
anus,    each    about    1    centimetre    from    the    anal 


OPERATIONS  ON  THE  ANAL  REGION         201 

border.  An  index-finger  is  then  passed  into  the 
rectum  ;  with  care  this  may  almost  always  be  done 
without  causing  pain.  If  in  the  given  case  the 
parts  are  too  sensitive  to  admit  of  this,  it  is  pos- 
sible, after  some  practice,  to  dispense  with  the 
introduction  of  the  finger.  The  needle  is  then 
introduced  at  the  four  injection  points  in  succes- 
sion and  passed  along  the  inner  aspect  of  the 
external  sphincter,  infiltrating  as  it  goes  (1  or 
•5  per  cent,  novocain  solution),  until  the  finger 
in  the  rectum  feels  the  submucous  swelling  caused 
by  the  injection.  Finally,  a  subcutaneous  injec- 
tion is  made  around  the  anus.  As  a  rule,  after 
five  to  seven  minutes  it  is  found  possible  to 
dilate  the  sphincter  without  pain,  and  when 
this  is  so  any  operative  procedure  about  the 
anal  region  may  be  embarked  on  without  mis- 
giving. 

Most  cases  of  anal  fistula  are  suitable  for  opera- 
tion under  local  anaesthesia,  particularly  if  the 
fistula  be  internal  to  the  sphincter.  Braun's  failure 
to  get  good  results  in  operations  on  periproctitic 
abscesses  is  to  be  attributed  to  his  use  of  too 
dilute  ('25  per  cent.)  solutions.  I  always  employ 
1  per  cent,  novocain-suprarenin  solution,  and  in- 
clude the  fistulous  sinus  or  the  abscess  in  the  area 
of  injection.  Owing  to  the  lax  condition  of  the 
tissues  in  the  anal  region,  which  enables  them  to 
absorb  considerable  quantities  of  fluid,  large  doses 


202  LOCAL  AN^STBESIA 

are  often  required.     I  have,  however,  never  seen 
any  untoward  effects. 

It  need  hardly  be  said  that  major  operations, 
such  as  the  removal  of  carcinomata,  are,  in  this 
region,  not  suitable  for  local  anaesthesia. 


INDEX 


Abdomen,  operations  on  the,  175  • 

92 
Abdominal  cavity,  sensibility,  176- 

80 
Abel,  investigations,  42 
Abscesses  : 

encapsuled  perityphilitic,  183 
extra-peritoneal,  183 
glandular,  157-58,  170 
lymphadenitic^  146 
periosteal,  131-32 
periproctitic,  201 
Abscesses,  puncture  of,   100,   104, 

141-42 
Achilles  tendon,  172-73 
Adenoid  vegetations,  removal,  120- 

22 
Adrenalin,  31,  42 
Air-bubbles  in  veins,  71 
Alffi  nasi,  118 
Alcohol,  78 

Aldrich,  investigations,  42 
Alexander-Adams,     operation     of, 

192 
Alkali,   free,   effect   on   suprarenin 

preparations,  45-46,  82 
Alkaline  solutions,  79 
Alveolares,  rami,  129,  132 
Alveolaris  inferior,  nervus,  10,  66, 

85,  103,  137-42 
Alypin,  use  of,  25,  28,  29,  31,  57, 

114,  119-20,  122,  124,  128.  149 
Alypin-suprarenin    solutions,    122, 

148 
Ammonia,  44 
Amputations,  67,  73,102-3.  160-61, 

172 
Amyl-nitrito,  26 
Anaemia   by   cocain,  18-19,   27-28; 

cedema  produced  by,  42 


Anaesthesia  dolorosa,  15,  20 

Ansesthyl,  3 

Ansestol,  36 

Anal  region,  anesthetization  of 
the,  8,  193-202 

Analgesia,  circular,  of  Hacken- 
bruck,  64-66,  98-99,  106-7,  111, 
141-45,  148-49,  152,  172,  180, 
186,  192,  199;  dosage  of  syn- 
thetic suprarenin  for,  47 

Anastomoses,  129,  130,  138,  140, 
145,  164,  165 

Angioma,  36 

Antrum  of  Highmore,  136-37 

Anus,  artificial,  181,  183 

Aorta,  74 

Aponeuroses,  101 

Appendicitis,  183-84 

Applicators,  122 

Aran,  cited ^  5 

Arm,  veins  in  the,  89-90  ;  upper, 
operations  on,  158  59,  161,  168 

Arnott,  2 

Arterenin  (arterenol),  44 

Arterial  anfesthesia,  74 

Arterial,  sclerosis,  50 

Articular  capsules,  104 

Asepsis,  60,  62,  125 

Auditory  meatus,  external,  111-13, 
115,  117 

Auricularis  magnus,  nervus,  106, 
111,  145 

Auriculo-temporalis,  nervus,  106, 
111 

Axillary  glands,  153 

Axillary  region,  ojjerations  on,  157 

j  IJandage,  Esmarch,  12,  86 
j  liartholini,  glands  of,  199 
ji    Basilica  vena,  86,  89-90 

203 


204 


LOCAL  ANESTHESIA 


Bassini,  operations  on  free  hernias, 

189-92 
Benzine,  107 

Bier,  method  of  venous  ansesthesia, 
11-12,  41,  60,  67-73,  79,  86-92, 
132,    147,    151,    157,    161,    166, 
169-73,  200 
Bladder,  anaesthesia  of  the,  25,  55 
Boils,  52,  53,  100,  112,  152 
Bone,  anaesthesia  of,  103,  104,  117 

132-33,  154-55,  164,  170 
Bone-marrow,  infiltration,  69 
Boric  acid,  43 
Bostely,  observations,  127 
Bouisson,  method  of  anaesthesia,  5 
Brachial  plexus,  158 
Brain,  insensibility  of  the  surface 

107 
Braun,   method   of  anaesthesia    2 
9,  11,   15,  16,  19,  20,  104,   io7, 
112,  118,  139-40,   143,  144,  159 
166-67,   171,    172,    182,    189-90.' 
195,    197,    200-2;     on    use     of 
cocain,  25,   27,    28  ;    on  use   of 
ether,  35,  39 ;  on  eflTects  of  liga- 
ture, 38,  40  ;  on  use  of  suprarenal 
preparations,  42-45,  47-49,  80-82; 
attack  on  Schleich's  method,  59 ' 
Breast,  tumours  of  the,  153-54 
Bromethyl,  3 

Bronchocele,  removal,  147-48 
Briming,  cited,  29 
Buccal  cavities,  operations  on,  119- 

23 
Bulb,  suture  of  wounds  of  the,  126  ; 

enucleation  of  the,  127 
Biinte,  cited,  130,  140 
Bursa  olecrani,  159,  171 
Bursa  patellae,  171 
Bursae,  subdeltoid,  158 
Byk,  42 

Caecum,  the,  184 

Caffeine  used  hypodermically,  26. 

28 
Camphor,  use,  26,  28 
Cancerous  growths,  100,  101 
Cannula,  use  of,  70,  79,  90,  128 
Canthus,  inner,  123 
Carbolic  acid,  63,  114 
Carbonic  acid,  6,  36 
Carbuncles,  53,  100,  152 


Carcinomata,  144,  202 

Carious  foci,  155-56 

Cartilage,     anaesthesia     of,    103-4, 

118  ;  resection  of,  155 
Castrations,  198-99 
Catgut,  60 

Catheterization,  193-94 
Cauterization,  125,  199 
Cephalic  vein,  89 
Cerebral    bloodvessels,    action    ot 

cocain,  21 
Cerebro-spinal   nerves,   sensibility, 

Cervical  glands,  145-46,  170 
Cervical  region,  operations  on  the, 

145-52 
Chalazia,  125 

Cheek,  operations  on  the,  143 
Chemical  factors,  Scheich's  view  of 

use,  41-42 
Chemical  means  of  producing  local 

anaesthesia,  4-12 
Chemosis,  126 
Children,     operations     on.     Biers 

precautions,  70 
Chlorethyl,  use   of,    3,    33-35,   39, 
52-54,  94,  131-32,  163,  168,  174 
Chlormethyl,  36 

Chloroform,    anaesthesia   by,   5,  6, 
76,177  -^      '     ' 

Choana,   appendage  to  the,  sensi- 
bility, 121-22 
Cicatricial  tissue,  102 
Circular    anaesthesia.      See    Anal- 
gesia, circular. 
Circumcision,  196-97 
Clavicle,  operations  on  the,  155 
Cocain,  use  of,  6-8  ;  substitutes  for, 
11,  18-19.  27-31  ;  action  of,  19- 
21,     48;     solutions,     Schleich's 
formulae,  22-23,  57,  59;    sterili- 
zation of,  26-27  ;  dosage,  49,  54, 
55,    65,    132,     133,     149,    194; 
anode  used  with,   51;   effect  on 
the  tissues,  60;   use  in  arterial 
anaesthesia,   74;    for  eye  opera- 
tions, 124-25 
Cocain,  crystals  of,  126 
Cocain-adrenalin  solution.  114 
Cocain-chlorethyl,  38 
Cocain-poisoning,    21-26,    55,   119- 
20 


INDEX 


205 


Cocain-suprarenin     solution,     121, 

126,  127 
Cold,  anaesthesia  produced  by,  2-3, 

31-36,  38-39,  52-54 
Colporrhaphy,  199 
Combined  anaesthesia,  76 
Compression  of  nerves,  local  anes- 
thesia produced  by,  1-2 
Conduction  anaesthesia,  method  of, 

7,    9-10,    50,    63-68,    84-85,    93, 

95-98, 118,  132,  133,  138-39,  143- 

44,  162-63,  166-67,  198 
Conjunctiva,  29,  54,  123-25 
Contracture,  Dupuytren,  166 
Contractures,  reflex,  56 
Convulsions,  48 

Cord,  spermatic,  191-92,  198-99 
Cords,  lymphangitic,  169 
Corks,  india-rubber,  44,  80 
Corning,  monograph  on  use  of  co- 

cain,    7  ;     method    of    regional 

anaesthesia,  9  ;  on  ligature,  40  ; 

method  of  conduction  anaesthesia, 

63  ;  experiments,  162 
Coronoid  process  of  the  lower  jaw, 

139 
Cortex,   cerebral,   action  of  cocain 

on,  21 
Cotton-wool  pledgets,  use  of,  112- 

14,  120,  121,  122,  134,  195 
Crile,  operation  on  the  shoulder,  158 
Cushing,  method,  67,  189 
Cutaneus    antebrachii,    nervus.    9, 

89-90 
Cutaneus  colli,  145 
Cystoscopy,  193-94 
Cysts,  hydatid,  183 

Dastra,  cited,  26 

Dental  plexus,  129,  130 

Dental  surgery,  use  of  the  galvanic 
current,  51 ;  use  of  suprarenin 
novocain,  82;  practical  import- 
ance of  anaesthesia  in,  131-43 

Dentalis,  nervus,  132 

Dentine,  operations  on,  133-34 

Desault  cited,  2 

Deschamps'  needles,  87 

Diffusion  anfesthesia,  98,  99,  132 

Direct  an;cstlie.sia,  69,  71,  92 

Dogs,  experiments  on,  176 

Dorsal  nerve,  162-65 


Dorsum,  the,  89,  163,  165,  174 
Drainage  anaesthesia,  16 
Due,  Le,  4 

Dupuytren,  contractiire,  166 
Dura  mater,  sensibility,  107 

Ear,  operations  on  the,  111-18 

Ear-drum,  sensibility,  114 

Eichen,  method,  112 

Elastic  ring,  use,  162 

Elbow,  operations  on  the,  90,  158- 
59,  161 

Electric  current,  anaesthesia  pro- 
duced by,  4,  51 

Embolism,  71 

Empyema,  evacuation  of,  154 

Endermal  injection,  13,  17 

Endoneural  injection,  10,  64,  67, 
158,  189 

Enucleation  of  the  bulb,  127-28 

Eosin,  solution  of,  37-38 

Epiglottis,  150 

Epirenan,  42 

Epithelium,  corneal,  danger  of  in- 
jury to,  123,  124 

Erythroxylin,  antesthesia  by,  6-7 

Esmarch  tourniquet  the,  12,  86 

Ether,  use  of,  2-3.  5.  32-33,  35,  76, 
107,  177 

Ethnoidal  nerve,  109,  118 

Ethyl  chloride.     See  Chlorethyl. 

Ethylene  chloride,  anaesthesia  by,  3 

Eucain,  use  of,  10,  19,  27,  28,  31, 
124,  128 

Exarticulations,  157-58,  174 

Extremities,  operations  on  the,  2, 
157-74 

Eye,  operations  on  the,  11,  111, 
123-28 

Face,  operations  on  the,  97,  110- 

11 
Fangs,  resection  of,  133-34 
Fascia  muscle,  101,  102 
Fauces,  the,  151 
Fehr,  Dr.,  123  note 
Femoral  vein,  89 
Femoral  glands,  170 
Femur,  condyle  of  the,  89 
Ferric  chloride,  43,  45 
Fibula,  172 


206 


LOCAL  ANESTHESIA 


Fingers,  ansesthesia  of  the,  10,  40, 
82,  103;  nerves  of  the,  66-67; 
Oberst's  method  of  interruption 
of  condiiction  in,  161-63;  techni- 
que of  injection,  163-64 

Fissure,  operations  for,  200 

Fistula,  anal,  201-2 

Flank,  the,  technique  for  an  in- 
cision, 182-83 

Flexor  carpi  ulnaris,  M.,  167 

Foci- 
carious,  155-56 
cutaneous,  168 
on  the  hands,  164,  166 
on  the  leg,  172 
osteomyelitic,  161 

Foci,  operations  for,  131,  142,  158 

Foot,  nerves  of  the,  10  ;  ansesthesia 
of  the,  172-74 

Forceps,  199 

Foramen  incisivum,  130 

Foramen  infraorbitale,  130 

Foramen  mentale,  138 

Foramen  palatine,  130 

Forearm,  operations  on  the,  66,  73, 
91-92, 158-61,  168 

Forehead,  operations  on  the,  105-9 

Foreign  bodies,  removal,  98,  101, 
125 

Freund,  operation  by,  155 

Frey,  observations  of,  150 

Frontal  sinus,  trephining,  109 

Frontalis  nervus,  106 

Fundus  uteri,  sensibility,  176 

Furuncles,  64-65,  98,  110,  113 

Galea,  the,  107.  108 

Gall-bladder,  179 

Ganglion  spheuo-palatinum,  130 

Gangrene,  50,  70 

Gastrostomy,  177,  179,  181,  183 

Genito-femoralis,  nervus.  188 

Genito-urinary  tract,  operations  on, 

8,  193-202 
Glands — 

axillary,  163 

Bartholini,  199 

cervical,  145-46,  170 

femoral,  170 

inguinal,  170 

thyroid,  147 
Glandular  abscesses,  157-58 


Glosso-pharyngeal  nerve,  113 
Gluteal  region,  96 
Gonorrhoeal  syringe,  193 
Goyanes,  experiments,  74 
Gumboils,  153-54 

Haab,  observations,  126 
Hackenbruch,  method  of  circular 
anaesthesia,    10,    63,    64,    98-99, 
147-49  ;  rhombus  of,  182 
Hacker,  von,  cited,  3 
Haemorrhoids,  200 
Haike,  observations,  111  note,  120 

note 
Hall,  method,  10 
Hallstedt,  method,  10,  139 
Hand,  anaesthesia  of  the,   10,  73, 

161,  163,  165-69 
Head,  operations  on  the,  105-144 
Heidenhain,  method,  107-8; 
Heinze,  method,  16 
Henbane,  5 
Hernia — 

congenital,  192  note 

free,  189-92 

incarcerated,  177 

inguinal,  67,  185-86,  188,  190 

linea  alba,  of  the,  187. 

strangulated,  184-89,  192 

umbilical,  186 
Hernia,  operations  for,  184  92 
Herniotomy,  184-85,  188 
Hertzog,  and  the  galvanic  current, 

51 
Highmore,  antrum  of,  136-37 
Hocher,  cited,  60 
Hochst,  preparations  by,  42-46 
Hoffmann,  preparations  by,  45,  46 
Holocain,  124 
Homorenon,  44-45 
Hlibner,  139 

Hunter,  anaesthesia  by  cold,  2 
Hydatid  cysts,  183 
Hydrocele,   puncture  of,    55,   197- 

98 
Hydrochlorate  of  cocain,  18 
Hydrochloric  acid,  43,  45,  82 
Hydrocyanic  acid,  6 
Hyoid  bone,  150 
Hyothyroid  membrane,  150 
Hyperaemia,  28,  126 
Hyperaesthesia,  33  . 


INDEX 


207 


Hypotonic  solutions,  14 
Hyj)odermic  injection,  6 


17 


Ilio-hypogastric  nerve,  181,  188 
Ilio-inguiual  nerve,  181,  188 
Indian  liemp,  5 
Indigo  carmine  solution,  69 
Indirect  amesthesia,  69,  72,  90 
Infants,  cocainization  of,  26 
Infiltration   antesthesia,  Schleich's 
method,  8-9,  41-42,  46,  47,  56-65, 
67,  83-85,  87,  97-98,  117-18, 120, 
122,    132,    141-44,    146,    153-55, 
158,    160-61,    170,    172,    179-80, 
191-92,  195,  197 
Infiltration  pain,  19 
Inflamed    tissues,    injecting    into, 

85 
Infi-aorbital  foramen,  129 
Infraorbital    nerve,    anesthesia   of 

the,  10,  106,  129-30,  136 
Inguinal  glands,  98,  99,  101,  170 
Inguinal  hernia,    67,    185-86,   188- 

90 
Inguinal    regions,    nerves   of    the, 

188 
Injection — 

endermal,  13 
endoneural,  10,  158,  189 
perineural,  10 
subconjunctival,  124,  126 
subcutaneous,  105-6,  128,  171 
subgingival,  138,  140-41 
submucous,  128 
technique       for       conduction 
antesthesia,       85-86 ;        for 
dental  surgery,   134-35  ;  for 
circular  angesthesia,  148-49 
Instillation,  125-28 
Intercostal  nerves,  181,  188 
Intestine,  sensibility  to  pain,  176, 

178 
Intratrochlearis  nervus,  123 
Intravenous  injection,  48 
Iodine,  55,  107,  197 
Iridectomy,  124 
Iris,  anaiSthesia  of  the,  125-26 
Iris,  prolapse  of,  125 
Irritant  fluids,  injection,  104,  171, 

197 
Lschfeniia  of  tissues,  58,  60-61 
Isotonic  solutions,  14 


Jaw,  lower,  anaesthesia  of  the,  103, 
138-43  ;  nerves  of  the,  138 

Jaw,  upper,  nerves  supplying  the 
130 

Karger,  cited,  36 

Klapp,  experiment  in  ligature,  40 
Knee-joint,  operations  on  the,  171- 
^72 

Kofmann,  discoveries,  2 
Kolb,  method,  189-90 
Roller,  discovery  of,  7 
Koryl,  anaesthesia  by,  3 
Krogius,  method,  10 
Kuehnen,  35 

Lachrymal  sac,  operations,  122-23 

Lamella,  132 

Landerer,  7 

Laparotomy,  76,  183 

Larry,  2 

Laryngeal  mucous  membrane,  anae- 

thesia  of,  149-50 
Laryngeus  inferior  nervus,  150 
Laryngeus    superior    nervus.    150, 

151,  152 
Larynx,  anaesthesia  of  the,  7,  149, 

151-52 ;  extirpation,  151  ;  nerves 

of  the,  150 
Leg,  veins  of  the,  87-89;  anaesthesia 

of  the,  161  ;  operations,  172-74 
Lennander,  observations,  175 
Liebreich,  method,  15 
Ligaments,  sensibility,  104 
Ligation,     Heidenhain's     method, 

107-8 
Ligature,  anaesthesia  by,  40-41  ;  of 

the  fingers,  67  ;  on  a  vein,  90 
Linea  obliqua,  interna,  139 
Lingual  nerve,  137-140 
Liugula,  the,  137 
Lip,  anaesthesia  of  the,  118,  128 
Liver,  sensibility  to  pain,  176 
Lobule  of  Roser,  196 
Lossen,  discovery  of  cocain,  18 
Lucius,  cited,  29 
Lurnbo-inguinalis,  188 
Lupus  of  the  cheek,  97,  110-111 
Lymphadenitis,  98 

Magnet  operations,  126 
Malleolus,  inner,  89,  172 


208 


LOCAL  ANESTHESIA 


Mandragora,  5 

Mandrake-root,  5 

Manz,  method,  10 

Mastitis,  suppurative,  153 

Mastoid  process,  112,  113,  117 

Matas,  cited,  131 

Maurel,  on  use  of  cocain,  22 

Maxilla,  broken,  suture  of  a,  142, 
143 

Maxilla,  lower,  nerve  supply  of 
the,  137-38,  142 

Maxilla  temporalis,  109 

Maxillae,  tuber,  129,  134 

Maxillae,  upper  and  lower,  opera- 
tions on,  128-29,  130-31 

Meatus  urinarius,  194-95 

Median  nerve,  anaesthesia  of  the, 
166-67 

Median  vein,  89,  90 

Medulla,  infiltrating  the,  69  ;  sensi- 
bility, 102-3 

Meister,  cited,  29 

Membrana  hyothyroidea,  150 

Membrana  tympani,  sensibility  of 
the,  113-14 ;  anaesthesia  of  the, 
115-17 

Mental  foramen,  143 

Mentalis,  nervus,  106,  137-38,  140- 
42 

Merck,  preparations  by,  42 

Mesentery,  76  ;  sensibility  to  pain, 
176,  178| 

Metacarpal  bone,  164,  174 

Metacarpo-phalangeal  joint,  164, 
174 

Metethyl,  anaesthesia  by,  3 

Methyl  chloride,  anaesthesia  by,  3, 
36 

Monochlorhydrate  of  benzoyl,  28 

Moral,  cited,  129 

Morphia,  6,  57,  148 

Morphine  salts,  5 

Morphine-scopolamine  narcosis,  178 

Motor  nerves,  effect  of  cocain,  20- 
21 

Motor  paralysis,  71,  72,  173 

Mouth,  floor  of,  operations  on,  143 

Mucous  membrane,  anaesthesia  of 
the,  5,  16,  54-56,  96,  109,  120 ; 
operations  on,  11  ;  use  of  cocain 
on,  25,  29  ;  use  of  novocain  and 
alypin,  31  ;  buccal,  34-35,  134 


Miiller    on    dosage    of    suprarenal 

preparations,  49 
Muscles,  insensibility  to  pain,  102 
Mydriasis,  29 

Nasalis  ext.,  nervus  ethmoidalis, 
R.,  106 

Nasopalatinus,  nervus,  130,  135 

Neck,  boils  on,  152 

Necrosis,  15,  187 

Necrotomy,  170-71 

Needles,  78-79 

Deschamps',  87 
hollow,  94-95 
injection  of,  90 
right-angled,  181 

Nerve-trunks,  anaesthetization  of, 
62-68,  71,  83-85,  97-99,  160  61 

Neugebauer,  cited,  50 

Niemann,  discovery  of  cocain,  7, 
18  ;  method,  115,  116 

Nirvanin,  27 

Nose,  operations  on  the,  7,  118-19 

Novocain,  use,  11-12,  25,  27,  29- 
30,  41,  55,  119-20,  124.  137  ; 
dosage,  49,  65,  69-70,  91-92,  95- 
97,  100,  102,  104,  110,  122,  128, 
133-34,  142,  143,  145-46,  181, 
186,  188,  190-91,  195-98,  201; 
effect  on  the  tissues,  60,  133  ; 
sterilizing,  80 

Novocain-suprarenin  solution,  use, 
109,  120,  127-28  ;  dosage,  112- 
17,  133-36,  139-40,  147-52,  154- 
55,  159,  163-67,  170-72,  182-83, 
193-201 

Novocain  -  suprarenin  tablets, 
Braun's,  80-82 

Oberst,  method,  10,  30,  40,  66-67, 

162-63 
Occipitalis  major,  nervus,  106 
Occipitalis  minor,  nervus,  106 
CEdema,    artificially   produced    by 

Schleich,  8,  11,  41-42,  58,  61,  83- 

84,  141,  179-80  ;  pulmonary,  48 ; 

pressure   cedema,    95 ;   in  dental 

surgery,  134 
(Esophagus,  120 
Oily  solutions,  use,  125 
Olecrani,  bursa,  159,  171 
Oliver,  investigations,  42 


INDEX 


209 


Omentum,  sensibility,  176,  178 
Ophthalmology,   anaesthetics  used 

in,  7,  27-29 
Opium,  use,  5,  149 
Oppel,  experiments,  74 
Orthoform,  27 

Osmotic  tension,  4,  11,  13-17 
Osteomyelitic  foci,  161 
Ovariotomy,  53-54,  179 

"Painting,"  anaesthesia  by,  96-97 
Palate,  operations  on  the,  135-36 
Palatine   nerves,    infiltration,  130, 

135 
Palniaris  longus,  M.,  166 
Palpebral  reflex,  125 
Panophthalmitis,  suppurative,  127 
Paracentesis,  116 
Paraflin,  79 

Paralysis  of  accommodation,  29 
Paranephrin,  42 
Paraphimosis,  197 
Parenchymatous  injections,  48 
Parietal  peritoneum,  sensibility  of, 

176,  179,  184 
Parke -Davis,  preparations  by,  42 
Parulis,  incision  of  a,  99,  141,  146, 

170 
Patellse,  bursa,  operations,  171 
Pelikan,  method,  6 
Pellacini,  investigations  of,  42 
Penis,  operations  on  the,  195-97 
Percival,  method,  6 
Perichondrium,  103-4 
Perineum,  ruptured,  suture  of,  199 
Perineural  method  of  injection,  10, 

63,  66,  68,  73 
Periosteum,    infiltration     of    the, 

69,  108-9,  154,  159  ;    sensibility, 

102-3  ,     nerves     supplying    the 

raaxillffi,  129.  130,  132-35,  137 
Peripheral  nerves,  64 
Peritoneum,  incision  of  the,  182 
Perityphlitis,  181 
Pernice,  method,  10 
Petrow,  use  of  suprarenin,  72 
Pharynx,  anfesthesia  of  the,  55, 120 
Phenol,  55,  84,  87 
Phenol-cocain  solution,  113-14 
Phimosis,  operation  for,  195  96 
Phlegmons,  treatment  of,  52,  167- 

69,  174 


Pinna,  operations  on  the,    111-12, 

115 
Plasters,  5 

Plastic  operations,  110,  118 
Platino-iridium  needles,  78 
Pleura,  puncture  of  the,  154-55 
Plexus,  brachial,  158 
Plexus,  den  talis  inferior,  137 
Poppy,  5 
Poultices,  5 

Poupart,  ligament  of,  189,  191 
Pressure,  anesthesia  by,  11 
Pressure  sensations,  20 
Protoplasm,    chemical    affinity    of 

cocain  for,  19 
Pterygo-palatine  fossa,  129,  131 
Pyriform  aperture,  137 

Quaddelanasthesie,  9,  93-95,  97 
Quellungsanasthesie,  14,  15,  59 
Quellungschmerz,  15,  19 

Radial  nerve,  161,  166;  anaesthesia 

of  the,  167 
"Eadical"  operations,  117 
Rami  alveolares,  129,  130 
Rami  cutanei  ant.,  188 
Reclus,   use   of    cocain,    8-9,    24  ; 

method   of  anaesthesia,  56,  172. 

194,  197 
"Record"  syringe,  77,  122 
Rectum,  200 
Rectus,  181 

Regional  anaesthesia,  9-10 
Renal      parenchvma,      sensibility, 

176 
Resections,    73,    103,    120,   133-34, 

154-55,  161 
Retrosternal  extension,  147 
Rhino-laryngology,  29 
Ribs,  resection,  103,  154-55;  carious 

foci,  operation  for,  155-56 
Richardson,  ether  spray  apparatus, 

3,  5,  32-33 
Ritter,  observations,  176 
Roberts,  method,  9 
Rochet,  anaesthesia  by  ether,  2-3 
Roser,  operation  of,  196 
Rossbach,  cited,  3 
Rubber  bands,  use  of,  162-63,  165, 

173-74 
Rupprecht  method,  114,  120-21 
14 


210 


LOCAL  ANESTHESIA 


Salt  solutions,  use  of,  15-16,  42,  48, 

52,  57-60,  70,  77,  79-82 
Salves,  use  of,  125 
Saphenous  nerve,  87-89 
Saphenous  vein,  extirpation  of,  170, 

173 
Saponin,  anaesthesia  by,  6 
Scalp,  anaesthesia,  95,  96,  99,  103  ; 

operations  on  the,  105-9 
Scapula,  resection  of,  53-54 
Schafer,  investigations,  42 
Scheff,  method,  5 
Scheller,  cited,  3 
Scherzer,  use  of  cocain,  6 
Schleich,  method  of  infiltration,  8- 
9,  11,  16,  39,  41-42,  56-63,   67, 
69,  83-85,  93-94,  97,  99-103,  117, 
122,  127,  132,  141-42,  146,  153- 
55,  158,  160-61,  170,  172,  177, 
179-80,    186,    188,   191-92,    195, 
197  ;  method  of  using  cocain,  22- 
23  ;  of  alypin,  29 ;  and  suprare- 
nal preparations,  50-51 ;  method 
with  inflamed  areas,  64-65 
Schlofi"er,  use  of  alypin,  29 
Sclerotic,  puncture  of  the,  128 
Scrotum,  operations  on  the,  197-99 
Sensory  nerves,  58,  61,  93,  95,  97, 

102,  111 
Septum,  118;  resections,  120 
Serous  surfaces,  anaesthesia  of,  54-56 
Shoulder,  operations  on   the,  157- 
58 ;     exarticulation   of   the,    by 
Crile,  158,  174 
Simpson  method,  6 
Skin,  anEesthesia  of  the,  16,  93-95, 

199;  grafts,  removal,  159,  169 
Smell,  sense  of,  action  of  cocain,  20 
Soakage  anaesthesia,  16 
Soda  solutions,  77 
Sounds,  use  of,  122 
Specula,  use,  199 
Spermatic  cord,  191-92,  198-99 
Spermaticus  externus,  nervus,  188 
Speyer,  cited,  36 
Sphincter  ani,  operations  for,  200- 

201 
Spinal  anaesthesia,  27,  67,  73 
Splinters,  visible,  52 
Spray,    cocain-suprarenin    applied 

by,  121 
Sternocleido-mastoid,  145,  158 


Sterno-mastoid,  148 

Sternum,  anaesthesia  of  the,  103  ; 
carious  foci,  operation  for,  155-56 

Stolz,  preparations  by,  44 

Stomach,  sensibility,  176,  177-78 

Stovain,  use  of,  29 

Strabismus  operations,  126-27 

Stricture,  194 

Strumectomies,  145 

Strumous  glands,  65 

Subconjunctival  injection,   17,  28, 
124,  126-28 

Subcutaneous  infiltrations,  142-43, 
155 

Subdeltoid  bursae,  158 

Subgingival  injections,  138,  140-41 

Submucous  infiltrations,  142,  144 

Superiosteal  infiltrations,  117,  142, 
154,  155 

Suction  apparatus.  Bier,  153 

Sulcus  bicipitalis  internus,  89 

Sulcus  bicipitalis  lateralis,  89 

Sulphuric  ether,  2-3,  32-33,  35 

Suppuration,  168,  171 

Suppurative  mastitis,  153 

Supraclavicularis,  145 

Supraorbitalis,  nervus,  106,  131 

Supra-  and  infra-trochlearis  nervus, 
106 

Suprarenal  gland,  11 

Suprarenal  preparations,  use  of,  25 
28,  29,  31,  41,  56,  67,  80-82,  87 
95,   96,   97,   104,  109,  120,   125 
162  ;    nature  and  action  of,  42 
51 ;    preparations   by   synthesis 
44-46,    82-83,    147  ;   dosage,  46 
47,    49,   82-84,   107-10;    dangers 
associated     with     use,     50-51 
abandoned  by  Bier,  72 
Suprarenin  hydrochloride,  43,  45 
Suprarenin-poisoning,  48-49 
Suprareninum  syntheticum,  43-47, 

83 
Surgical  Congress,  1892,  9;    1908, 

68  ;  1909,  11,  60 
Sutures,  95,  142,  143,  199 
Sympathetic,  the,  175 
Synovial  membrane,  104,  171 
Syringes,  injection,  77-79.  122,  193 

Tactile  sensations,  20 
Takamine,  investigations,  42 


INDEX 


211 


Taste,  sense  of,  action  of  cocain,  20 
Teeth  extractions,  anaesthesia  for, 

39,  54,  138-43 
Temperature,     difference    of,     im- 
portance, 61 
Tendons,  101,  102 
Tenotomy,  166,  172 
Terminal  anaesthesia,  9,  32,  54,  93, 

95 
Thenar  eminence,  166 
Thiersch,    removal  of  skin  grafts, 

159,  169 
Thigh,  ansesthesia  of  the,  170-71 
Thorax,  operations  on  the,  153-56 
Thumb,  the,  166 
Thymol,  43 
Thyroid  cartilage,  150 
Thyroid  gland,  removal,  147 
Tibia,  172 

Tiefenthal,  method,  114 
Time  for  completion  of  ansesthesia, 

84,  85,  96 
Tissues,  inflamed,  infiltration,  99 
Toe,  ansesthesia  of  the,  5,  40,  66, 

174 
Toe-nail,  ingrowing,  54,  174 
Tongue,  operations  on  the,  143-44 
Tonsils,  extirpation  120-22 
Tourniquets  : 

Bier's  use  of,  69,  71,  72,  86-87, 
173-74 

effect  of  application  on  absorp- 
tion, 40-41 

Esmarch's   12 

Oberst's  method,  162 
Trachea,  149,  151 
Tracheotomy,  149 
Traction,  76 
Trephining   operations,    107,    109, 

117,  136-37 
Trigeminus,  129,  131 
Tropacocain,  17,  27-28,  124 
Tumours  : 

aseptic  cystic,  146 

cauterization,  199 

cystic,  183 

glandular,  170 

mammary,  153-54 


Tumours  : 

nasal,  118 

ovarian,  179 

removal^of,  98,  100-4,  110,  118 
Tiirck,  investigations,  5,  42 
Tympanic  epithelium,  114 

XJlnse  capitulum,  167 

Ulnar   nerve,    161,  164,   165,  166; 

injection  for  the,  167 
Umbilicus,  186 
Urethrotomy,  193-94 

Vagina  fixations,  199-200 

Vagus  nerve,  111,  113 

Vaso-coustriction,  49,  51 

Vaso-dilatation,  51,  124 

Veins,  risk  of  injecting  into,  85-86, 
148;  exposure,  87-90;  course  in 
the  lower  extremity,  88-89 ; 
course  in  the  arms,  89-90 ;  ex- 
tirpation of  saphenous,  170 

Vena  cava  inferior,  74 

Venous  ansesthesia.  Bier's  method, 
12,  20,  41,  67,  69,  132,  157,  166, 
169-73;  dosage  for,  68-73; 
syringes  for,  79 ;  technique  of 
Bier's  method,  86-92;  priority 
of,  104 

Vesical  mucosa,  193,  195 

Vitreous,  prolapse  of,  125 

Vocal  cords,  150 

Volar  nerve,  162,  164,  165 

Vomiting,  125 

Wagner,  51 

Water,  injections,  58,  59 

Wheal  method  of  anesthesia.  13-17, 
19.  57,  93-95,  97,  99,  112,  141, 
148,  151,  163,  181,  186,  188,  190, 
191,  199 

Whitlows,  52 

Woehler,  laboratory,  7,  18 

Woelfler,  7 

Wood,  discovery  of,  6 

Zygomatic  process,  129,  134 
Zygomat.  temporalis  nervus,  106 


BILLINO    AND   SON'S,    LTD.,    PRINTERS,    OUILUKORD 


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Local  anaesthesia. 


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Local  anesthesia 


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